Structured Psychiatric and Psychological Assessment
The demographic characteristics of the 34 individuals (28 cases of AHI and 6 cases of early HIV infection) who were enrolled in the study are presented in a companion piece in this issue [
12]. In brief, participants were predominantly Caucasian or Hispanic gay men in their late 20s or early 30s, who had at least some college education. Psychiatric history, as assessed by the M.I·N.I. Plus, is described in Table
1. The vast majority of participants (29 of 34; 85.3%) met criteria for a lifetime history of an alcohol or other substance use disorder, with more than half (21 of 34; 61.8%) meeting criteria for a recent (within the past 12 months) disorder. Furthermore, a majority of participants (18 of 34; 52.9%) met criteria for a lifetime diagnosis of mood disorder, either major depressive disorder or bipolar disorder. Co-morbidity—the lifetime occurrence of two of more conditions (e.g., alcohol use disorder and mood disorder)—was characteristic of the sample, with 18 participants (52.9%) having two or more disorders.
Table 1
Lifetime and recent prevalence of DSM-IV disorders in acute HIV infection (N = 34) compared to US lifetime estimates from population-based community surveys
Major depression (%, No.) Recent (last 2 weeks) lifetime | 8.8 (3) 29.4 (10) | 14.0a
|
Bipolar disorder (%, No.) Recent (current) lifetime | 2.9 (1) 23.5 (8) | 4.4a
|
Alcohol use disorder (%) Recent (last 12 months) lifetime | 41.2 (14) 79.4 (27) | 9.7a 36.7a
|
Other substance use disorder (%) Recent (last 12 months) lifetime | 52.9 (18) 64.7 (22) | 1.9a
14.3a
|
Current suicide ideation Lifetime suicide attempt | 20.6 (7) 32.4 (11) | 3.3b
5c
|
As assessed with the M.I·N.I. Plus, a substantial proportion reported having made a suicide attempt at some time in their life (11 of 34; 32.4%). As might be expected, all individuals reporting prior suicide attempts also met lifetime criteria for alcohol and/or substance use disorders; likewise a lifetime diagnosis of mood disorder was prevalent in those with suicide attempts (7 of 11; 63.6%). A significant minority of participants (7 of 34; 20.6%) reported some form of suicidal ideation in the past month. This consisted of endorsements of thoughts about suicide, thoughts about being better off dead or wishing one were dead, and thinking of harming oneself. None reported a suicide attempt in the past month. Current suicide risk assessment scores ranged from 0 to 24. The distribution of risk scores was as follows: no risk, N = 27; low risk, N = 3; moderate risk, N = 2; high risk, N = 2.
The relationship of mood and substance use disorders to sexual risk behavior was also assessed. The only finding that achieved even borderline statistical significance was that in the 2 months preceding documentation of HIV, those with a lifetime diagnosis of bipolar disorder (N = 8) reported more sexual partners than those with no lifetime mood disorder diagnosis (i.e., no major depression or bipolar disorder, N = 16) (18.3 ± 19.0 partners vs. 4.4 ± 4.5 partners; P = 0.06).
In terms of the timing of onset of psychiatric condition, all participants with a lifetime diagnosis of mood or substance disorder reported onset preceded notification of HIV infection. The inventories of current mood revealed mild depressive (mean BDI-II = 12.0 ± 8.9) and anxiety (mean state scale of the STAI = 36.4 ± 12.4) symptoms. The vast majority of participants were experiencing minimal (N = 21; 61.8%) or mild-moderate (N = 11; 32.4%) symptoms of depressed mood, while only two (5.9%) were experiencing severe depressive symptoms. Furthermore, participants reported greater use of adaptive coping approaches (summary Brief COPE adaptive domain score = 5.4 ± 1.1) compared to less-adaptive approaches to confronting their HIV diagnosis (summary Brief COPE less-adaptive domain score = 3.4 ± 1.1). This difference was highly significant (P < 0.0001).
In-Depth Interview Findings
Findings from the qualitative in-depth interviews corroborated those from the structured surveys. Respondents described the challenges of managing an HIV diagnosis in tandem with pre-existing substance abuse problems, depression, and anxiety. However, despite these challenges, several respondents appeared to be coping well, especially those well integrated into medical and social services and/or a community of other sero-positive individuals.
Although most respondents were coping well, in-depth interviews also revealed that psychiatric and substance disorders might have enhanced some individuals’ vulnerability to infection and adversely impacted post-diagnosis coping. For example, one participant described pre-existing co-morbidity with bipolar disorder and addictive behavior. “I tend to overdo a lot of things,” he said. “And I think I’m an addict with lots of different addictions: food, sex, et cetera.” When recounting his infection story, he reported:
I remember fucking this black guy. I remember him sneezing and stuff, or coughing. I thought perhaps he might have been sick. And then, you know, [HIV] crossed my mind, but I’m like, ‘Fuck it, I don’t care.’ I was pretty self-destructive. I still am pretty self destructive. (33-year old gay man, New York).
This respondents’ post-diagnosis coping also was compromised by his experience with depression and suicidality:
I’d called many help lines, searching for help, searching for help, psychiatrically. When I was in my lows…thinking about going out and getting a gun. [..] But there’s no help out there in New York City. So that’s the reason a lot of people just go ahead and [commit suicide], and I totally understand that, totally.
Other respondents’ infection and coping narratives were infused with substance abuse disorders, both as harbingers of infection and as factors in post-diagnosis coping. One participant described a long history of methamphetamine and cocaine use, which he factored into his HIV infection:
When you’re high, you don’t bother to ask anyone about HIV. [..] Do I think drugs have anything to do with me having [HIV]? Of course I do. (57-year old gay man from San Francisco).
Since diagnosis, this respondent had struggled to create a new, drug-free social network. Highlighting the cycle between mental illness and substance use, he also worried that anxiety about his diagnosis could lead him back to drug use. “I felt insecure enough without having HIV, he said. “Is this going to make me want to go back to past behavior with the drug use? It very easily could.”
In a final example of this theme, one respondent described a history of both depression and methamphetamine use (he also reported extreme BDI-II severity on his structured interview). He expressed anxiety about how to have sex without methamphetamine and how to access the help he needed:
I’m trying to get the right help. But I’m not doing it right…I’m making the wrong choices, you know? And I need help, but I can’t—I’m—I’m alone with this. (31-year old gay man, Los Angeles).
In keeping with the structured interview findings, a number of respondents described highly functional coping in the aftermath of their HIV diagnosis, despite some of the mental health challenges mentioned above. Qualitative data indicated that two factors tended to be most strongly associated with adaptive coping: good access to clinical and social services; and integration into a community of sero-positive people and/or a close relationship with another HIV-positive person.
One respondent suspected that he became infected through one of his short-term Internet partners, but his long-term partner of 7 years was also HIV-positive. Because of this latter partner, he not only knew what to expect in the progression of the disease, but he received immediate referrals to both doctors and support services: “I’ve gotten a lot information on educational programs and stuff like that. With [my partner], these things have helped me get my focus back on reorganizing my life. [..] Until I talked to them, I didn’t quite focus in on what the positive aspects of this could be (36-year old gay man, San Diego).
Similarly, another respondent seemed to be faring well after diagnosis, in large part because of the services available to him at his testing site, the Gay and Lesbian Center in Hollywood:
They offered me medical assistance, psychological assistance, financial assistance, um, moral assistance. [..] Being newly infected, I’m…I’m eligible for a whole bunch of stuff. You know, house…assistance in housing, assistance in medical care, and stuff like this. [..] I’m constantly amazed at the medical staff. (46-year old gay man, Los Angeles).
Perhaps due to this support, the above respondent had not used methamphetamine since diagnosis, and he was optimistic about his ability to stay clean.