The introduction of effective anti-HIV therapy has led to an improvement in the mental health of HIV-positive patients, even in those who have stopped treatment for reasons such as side-effects, or have never taken anti-HIV treatment, according to a US study published in the May 1 st edition of the Journal of Acquired Immune Deficiency Syndromes.
Rates of mental ill health and distress are thought to be approximately twice as high amongst HIV-positive patients as their HIV-negative peers, however, there is evidence that incidence of illnesses, such as depression has fallen since the introduction of highly active antiretroviral therapy (HAART) resulted in reductions in morbidity and mortality.
Investigators in San Diego wished to establish if the reductions in mental illness were associated solely with improved health on HAART, or if the availability of HAART had led to a general improvement in the mental health of HIV-positive patients, regardless of whether or not they had ever taken, stopped, or switched anti-HIV therapy.
The San Diego investigators recruited 2,466 patients, who were enrolled in the HIV Cost and Services Utilization Study (HCSUS). Baseline interviews were conducted in 1996 and early 1997 and follow-up interviews in late 1997. Information on the patients' age, sex, year of HIV diagnosis, HIV disease stage, drug use, CD4 cell count and HIV treatment history was gathered.
The mental health of patients was scored according to a scale for four mental illnesses: major depression; general anxiety disorder; panic; and dysthymia) at baseline and follow-up. Patients were divided into four categories dependent on their HIV treatment history: patients on stable HAART; patients starting HAART; patients switching/stopping therapy; and patients who had never taken HAART.
HIV-related ill-health had been experienced by 89% of the sample at baseline. Two thirds of the sample was over 35, and 51% was non-white. Heavy drinking and illegal drug use were recorded for 17% of patients.
During the period of the study, the number of patients with at least one psychiatric disorder fell from 48% to 38%. Over 50% of the sample had no psychiatric symptoms at baseline. Over 80% of these patients remained stable over the period of the study, and over 50% of patients who reported a psychiatric symptom at baseline improved by the time of their follow-up interviews.
Furthermore, mental health improved in all four groups of patients, regardless of their treatment history. In the stable treatment group incidence of mental illness fell from 47% to 41%; amongst patients starting treatment the fall was from 50% to 40%; in patients switching or stopping therapy, it fell from 51% to 37%; and amongst non-treated patients, the prevalence of psychiatric illness fell from 46% to 36%.
The general health of the study population had also improved, with patients reporting fewer symptoms of physical or mental illness, fewer opportunistic infections, and higher CD4 cell counts.
The investigators note that their study is the first to show a “global improvement in the mental health” of HIV-positive patients, "regardless of treatment profile.”
They add, “the fact that participants who never received (HA)ART experienced an improvement in mental health comparable to other treatment profile groups provides evidence of a global effect from (HA)ART, possibly by fostering general optimism about the future and quality of life.” However, it is notable that this study was conducted in 1996-97, when optimism about HAART was at its greatest, and longer-term side-effects, such as lipodystrophy, were still to be recognised.
Improved mental health amongst patients on stable treatment or people starting therapy could be explained by fewer illnesses and a general improvement in health. For patients stopping or changing treatment, improved mental health could be because of reduced side-effects.
The investigators conclude that “mental health improvement is a treatment benefit” of HAART, “and should be considered when calculating the cost and benefits of providing or broadening access to these treatments.”
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Mental health - factsheet
Chan KS et al. Combination antiretroviral therapy and improvements in mental health: results from a nationally representative sample of persons undergoing care for HIV in the United States. JAIDS, 33: 104 – 111, 2003.