Prevalence and Persistence of Psychiatric and Substance Abuse Disorders Among

Mothers Living with HIV

Kathleen Malee, Claude Mellins, Yanling Huo, Katherine Tassiopoulos,

Renee Smith, Susannah Allison, Suad Kapetanovic, Deborah Kacanek,

Patricia Sirois, Paige Williams, Mitzie Grant, Daniel Marullo, Angela Aidala

for the Pediatric HIV/AIDS Cohort Study

January 14, 2013 International Workshop on HIV and Women

Toronto, Canada

Background

Women living with HIV are at high risk for Psychiatric Disorders

(PD) and Substance Abuse Disorders (SAD):

Biological mechanisms:

chronic illness

potential for chronically activated inflammatory pathways

increased risk for depression

Genetics

Environmental factors, including trauma

Psychosocial challenges

poverty, stress, limited resources

Background

Early studies:

High lifetime prevalence of Psychiatric and/or Substance

Abuse Disorders

often under-recognized and undertreated

31% prevalence of depression during pregnancy

associated with substance abuse in pregnancy, past history

of psychiatric disorder

Few studies investigated prevalence and persistence of disorders

among mothers living with HIV in the era of HAART

Risks Associated with Psychiatric and Substance Abuse Disorders in

Mothers Living with HIV Mothers:

Inconsistent ART utilization/poor adherence

HIV disease progression

especially once the intense prenatal experience ends

Children:

Delayed cognitive and/or language development

Impaired parent-child relationships, maltreatment

Disruptive behavioral disorders

Poor school and social adaptation

Depression and anxiety disorders

Study Objectives To examine the prevalence and types of Psychiatric and

Substance Abuse Disorders among mothers living with HIV

infection.

To estimate, in a subset of mothers with HIV who had at least two

mental health evaluations, the proportion with: a) remitting, b) new,

and c) persisting disorders.

To identify key biomedical and psychosocial factors significantly

associated with: a) prevalent and b) persistent Psychiatric and

Substance Abuse Disorders.

Study Population Prospective cohort study: Surveillance Monitoring of ART Toxicities

(SMARTT)

22 sites in the United States, including Puerto Rico

1223 biological mothers of HIV-exposed but uninfected children

evaluated for prevalent disorders:

689 completed initial and follow-up evaluations 1-3 years

later and were evaluated for persistence of Psychiatric

and/or Substance Abuse Disorders

128 mothers without HIV, enrolled at 9 of the 22 SMARTT sites,

were included as a comparison group for prevalent disorders

Client Diagnostic Questionnaire-CDQ Aidala et al., 2004

Psychiatric screening tool based on the PRIME-MD, developed to assess most common disorders in adults affected by HIV (Spitzer, Kroenke,Williams, 1999).

Psychiatric Disorders Major Depressive Disorder Other Depressive Disorder Panic Disorder Generalized Anxiety Disorder Post-traumatic Stress Disorder Psychosis

Substance Abuse Disorders Alcohol Abuse Disorder Substance Abuse Disorder

Background Characteristics HIV+ (N=1223) HIV- (N= 128) P-value*

Race: Black 751 (67%) 85 (69%) 0.69

Ethnicity: Latina 429 (35%) 33 (26%) 0.04

Age ≥ 35 years 407 (33%) 25 (20%) 0.001

Education ≥ high school 803 (66%) 104 (81%) <0.001

Employed 458 (38%) 71 (55%) <0.001

Functional Limitations

0

1-2

≥3

790 (65%)

311 (26%)

108 ( 9%)

105 (82%)

16 (13%)

7 (5%)

<0.001

Mental health treatment 136 (11%) 9 (7%) 0.18

* Fisher’s Exact Test

Background Characteristics HIV+ HIV- P-value*

Alcohol use during pregnancy 121 (10%) 8 (6%) 0.21

Illicit substance use during

pregnancy 115 (10%) 4 (3%) 0.01

Health problems

0

1

2

≥3

0 (0%)

720 (60%)

289 (24%)

200 (17%)

88 (69%)

21 (16%)

12 (9%)

7 (5%)

<0.001

WASI Full Scale IQ: Mean (s.d.) 86.7 (13.4) 91.3 (13.7) <0.001

* T-Test with Equal Variance for Full Scale IQ; Fisher’s Exact Test for others.

Prevalence of Psychiatric and Substance Abuse Disorders by HIV Status

0%

5%

10%

15%

20%

25%

30%

35%

40%

Any PD/SAD Any PD Any SAD

HIV+

HIV-

Prevalence of Specific Disorders

HIV+

N = 1223

HIV-

N = 128 P-value *

Any Anxiety Disorder 141 (12%) 16 (13%) 0.77

Any Depressive Disorder 146 (12%) 10 (8%) 0.19

Any Substance Abuse Disorder 107 (9%) 11 (9%) 1.00

Psychosis 52 (4%) 3 (2%) 0.48

PTSD 281 (23%) 27(21%) 0.66

Co-morbidity 187 (15%) 16(13%) 0.39

*Fisher’s Exact Test

Types of Trauma Exposure HIV+

N=1223

HIV-

N=128 P-value*

Physical abuse during childhood 285 (24%) 18 (14%) 0.01

Sexual assault during adulthood 167 (14%) 8 (6%) 0.01

Prior experience of accident or

natural disaster 279 (23%) 44 (35%) 0.004

Prior experience of witnessing

violence or war

528 (44%) 71 (55%) 0.01

*Fisher’s Exact Test

Factors Associated with Presence of PD/SAD in Mothers with HIV Infection at Initial Evaluation: Multivariate Associations

Adjusted

Odds

Ratio

95%

Confidence

Interval

P-value

Age < 35 years 1.39 1.09 - 1.75 0.01

Single parenthood 1.35 1.08 - 1.68 0.01

Functional limitations ≥ 3 3.57 2.49 - 5.14 <0.001

Alcohol use during pregnancy 1.61 1.11 - 2.34 0.01

Illicit substance use during pregnancy 1.91 1.27 - 2.88 0.002

Psychiatric and Substance Abuse Disorders During Follow-up of Mothers Living with HIV (N=689)

0%

10%

20%

30%

40%

50%

60%

New PD/SAD RemittingPD/SAD

PersistingPD/SAD

Ever PD/SAD

13.5%

13.5%

21%

48%

Psychiatric and Substance Abuse Disorders During Follow-up of Mothers Living with HIV

79%

21%

39%

61%

0%10%20%30%40%50%60%70%80%

No newPD/SAD

New PD/SAD RemittingPD/SAD

PersistingPD/SAD

Among mothers with any disorder at entry (N=238)

Among mothers with no disorder at entry (N=451)

Factors Associated with Persistent PD/SAD vs. No Disorder in Mothers with HIV at

Follow-up (N=503): Multivariate Associations

Adjusted

Odds

Ratio

95%

Confidence

Intervals

P-value

Annual household income ≤ 20 K 2.44 1.33 - 4.76 0.01

Functional limitations ≥ 3 9.14 3.97 - 22.03 <0.001

Alcohol use during pregnancy 4.01 1.85 - 8.83 <0.001

Illicit substance use during pregnancy 2.46 1.12 - 5.46 0.03

Summary and Conclusions Psychiatric disorders and substance abuse disorders among mothers

living with HIV:

significant co-morbid conditions

persist in a significant portion of the mothers

Mothers living in high-risk communities:

similar risk for psychiatric and substance abuse disorders, regardless of HIV status

Limited use of mental health treatment programs and services by mothers in this study

Concern that disorders will exacerbate existing health problems and prevent adequate health-promoting behaviors for mothers with HIV, especially those with persistent disorders

Limitations Use of screening instrument to identify disorders:

CDQ is well-validated for assessing psychiatric disorders in

primary care settings and among populations affected by HIV. Sensitivity, specificity and overall accuracy are 91%, 78%, and

85%, respectively (Aidala et al., 2004).

Non-random selection of Reference comparison group

Lack of longitudinal data for Reference comparison group

Implications for Programs and Policy Screening, diagnosis and early treatment of PD/SAD should

be key components of comprehensive HIV care, especially for women at highest risk:

History of alcohol or drug use

Multiple functional limitations

Limited resources (income, family)

Psychological, societal, cultural and institutional barriers to mental health care must be identified and addressed.

Monitoring of children of women with PD/SAD is necessary, given increased risk for poor outcomes.

Special Thanks

We are especially grateful to all of the mothers who generously shared their experiences, thoughts and time with us during this longitudinal investigation.

Acknowledgements

We thank the Study Participants, PHACS Community Advisory Board, Frontier Science Inc., and Westat.

PHACS is funded by:

Under cooperative agreements with Harvard School of Public Health (HD052102, 3 U01 HD052102-05S1, 3 U01 HD052102-06S3) and Tulane School of Medicine (HD052104, 3U01HD052104-06S1)

Acknowledgments • The following institutions participated in

conducting PHACS: • Baylor College of Medicine • Bronx Lebanon Hospital Center • Children's Diagnostic & Treatment Center • Children’s Hospital, Boston • Children’s Memorial Hospital • Jacobi Medical Center • New York University School of Medicine • St. Christopher’s Hospital for Children • St. Jude Children's Research Hospital • San Juan Hospital/Department of Pediatrics • SUNY Downstate Medical Center

• Tulane University Health Sciences Center • University of Alabama, Birmingham • University of California, San Diego • University of Colorado Health Sciences Center • University of Florida/Jacksonville • University of Illinois, Chicago • University of Medicine and Dentistry of New Jersey • University of Miami • University of Southern California • University of Puerto Rico Medical Center