Among a sample of HIV-infected crack users in Atlanta and Miami, we found that almost two-thirds screened positive for depressive symptoms as measured by the BSI-18 depression subscale. This prevalence is substantially higher than the depression prevalence estimates of approximately 36% in nationally representative samples of adult HIV-infected individuals and higher than the 35% of participants at high risk for depression reported in a cohort of HIV-infected injecting drug users [37
]. However, our estimates were based on data from individuals receiving inpatient care and many of the current participants were not participating in routine HIV care. The current estimates are, however, comparable to the 80% of participants in a community-sample of crack cocaine users who reported more than minimal depression as measured by the Beck Depression Inventory [22
The profound co-existence of poverty, homelessness, food insufficiency and depressive symptoms are perhaps not surprising given the nature of our study sample, and are probably appropriately labeled a syndemic [46
]. The term “syndemic” was first coined by anthropologist Merrill Singer to describe the interaction among multiple diseases or health problems under conditions of poverty, health disparities, and structural violence resulting in an amplification of negative health outcomes. First postulated to examine the mutually reinforcing interaction among substance abuse, violence, and AIDS in inner city settings in the United States, the syndemic approach offers a useful framework for understanding the complexities of the spread of AIDS. The Centers for Disease Control states: “the conceptualization of a syndemic is significant because it expands the boundaries of public health science and action….This perspective complements single-issue prevention strategies that may be effective in controlling discrete problems but often are mismatched to the goal of protecting the public’s health in its widest sense” [48
]. Understanding the complex interacting challenges facing the HIV-infected crack cocaine user as a syndemic will improve our approach to developing services that address their unique challenges. This paper’s findings suggest that programs which simultaneously focus on alleviation of poverty, food insufficiency and homelessness among HIV-infected crack cocaine users will be essential to addressing their mental health needs.
Poverty, defined as low income, has a well-established relationship with depression [24
], and in this study, low self-reported income was strongly associated with screening in for depression. Interestingly, the associations between gender, educational achievement and marital status and screening in for depression in this study were opposite of those commonly reported in the literature [50
]. Male participants were more likely to report depressive symptoms. Single participants who were never married and those with less education were less likely to report depressive symptoms. These unexpected findings suggest that the predisposing factors for depression in HIV-infected crack cocaine users may differ from those in other HIV positive and HIV-negative drug using populations. Additional exploration of the socio-demographic correlates of depression in HIV-infected crack users is necessary to further explore and confirm these findings.
The experience of food insufficiency was significantly associated with screening in for depression, both on bivariate analysis and after controlling for other sociodemographic characteristics known to be associated with food insufficiency. The directionality of the association between food insufficiency and depression cannot be determined in this cross-sectional study. However, studies in HIV-negative households suggest food insecurity may influence health outcomes through depression [25
]. The longitudinal impact of food insecurity on the health behaviors and health outcomes of HIV-infected individuals and their households and depression’s role in this relationship has not been evaluated in the United States. Additional studies could provide valuable insight into the mechanism of food insecurity’s influence and the causal pathways linking food insecurity, depression and health outcomes in HIV-infected individuals.
Both food insecurity and depression have been linked to increased high-risk sexual behavior and decreased adherence to antiretroviral therapy [33
]. The coexistence of these potentially reinforcing conditions may make escape from either less likely. Programs and services directed towards alleviating food insecurity may improve HIV-infected patients’ mental and physical health, and in turn make it more likely that they will engage in care. Proactively assessing for and addressing food insecurity in HIV-infected crack cocaine users should be an essential component of care, especially given the limited social and economic resources at their disposal and the remarkably elevated prevalence in this group.
Our study has several limitations. First, the cross-sectional nature of the study precludes causal links between the presence of food insecurity and depressive symptoms. Second, because we analyzed responses from a sample being recruited from an inpatient hospital setting, our findings cannot be generalized to other HIV-infected drug users. Hospitalization may be a marker for inadequate coping skills that place these individuals at higher risk for depression than those HIV-infected crack users who are less likely to be hospitalized. In addition, we were unable to control for condition or severity of disease for which participants were hospitalized. If men were more ill when they were admitted to the hospital, that possibility may impact the observed gender difference in depression symptomatology. Third, the single-item measure of food insecurity does not reflect the full range or severity of food insecurity that may be experienced. Given survey constraints in this difficult to assess population, we initially opted to use a measure that was quick to assess. When compared to longer food security assessment tools, our single item indicates a rather severe stage of food insufficiency. Therefore, we may have underestimated the occurrence of food insufficiency by not using a more common scaled measure, which would have given respondents more opportunity to identify the presence of food insecurity. In addition, because we did not utilize a more commonly used scaled measure, our estimates are not directly comparable to other studies or national estimates. Despite the limitations of the single question measure, it is worth noting that several studies have noted high correlation between single-item measures of food insufficiency and scaled measures [38
]. Fourth, the analysis is based on self-reports and may be biased because of socially desirable reporting. Lastly, although we used a standard measure of depressive symptoms, we did not have data available on HIV somatic symptoms which may have lead to an over reporting of depressive symptomatology. In addition, the use of the BSI depression subscale instead of a clinician-administered measure of depressive symptoms may have improperly identified some individuals.
Our study findings provide insight into the complexity of factors associated with screening in for depression among HIV-infected crack users and reinforce the appropriateness of the term syndemic as a description of the mutually reinforcing social and clinical pathologies of this population. Food insufficiency and depression commonly co-exist among HIV-infected crack users. Because of the high prevalence of depressive symptoms and the association with food insufficiency, we recommend that caregivers screen all HIV-positive crack users for depression and food insecurity risk. The development of more widely available and accessible community-based and clinical services to alleviate food insecurity in HIV-infected populations has the potential to improve depressive symptoms and ultimately enhance the ability of HIV-infected crack users to engage in prevention and treatment services.