Among a sample of HIV infected patients receiving outpatient HIV related medical care at one of 14 sites affiliated with the HIV Research Network, we found that over a third reported receiving at least one outpatient mental health visit within the last 6 months. On average these patients attended 8 visits in a 6 month period. Utilization of outpatient mental health services was greater among disabled patients, current and former drug users as well as those with more primary care visits. Blacks were less likely to have an outpatient mental health visit compared to Whites.
We also found over a third reported utilizing psychotropic medication for a mental health condition. Antidepressant medication was the most commonly used psychotropic medication. About two thirds of those reporting use of psychotropic medication also reported utilizing mental health services and utilization of psychotropic medication was significantly associated with mental health visits. Utilization of psychotropic medications for a mental health condition was greater among women compared to men, among disabled patients, and those with more primary care visits. Blacks and Hispanics were less likely to use a psychotropic medication.
Consistent with the HCSUS data we found that those who were disabled were significantly more likely to utilize outpatient mental health services compared to those without disabilities. Also consistent with the HCSUS data we found that Blacks were less likely to utilize outpatient mental health services compared to Whites.[3
] This is similar to other studies in the general population that have found that African Americans receive less care for mental health conditions such as depression.[11
] It is also in accordance with finding from the HIV/AIDS Cost Study which found among HIV infected people with mental health and substance abuse disorders that African Americans self-reported receiving less mental health care in a 3 month time frame compared to Whites. [14
] Given the above and given that the HIV epidemic in America has disproportionately affected African-American and Hispanic people, future efforts to improve the delivery of mental health services to HIV infected people should focus on creating models of mental health care that is accessible, acceptable and culturally relevant to African-American and Hispanic people.
In contrast to the HCSUS study, we did not find that educational level was associated with increased mental health service use. This may reflect differences in the HCSUS vs. the HIVRN samples. For example, only 14% of our sample reported having a college/post-college education compared to approximately 46% of those in the HCSUS study. Although not directly evaluated in HCSUS, our adjusted analysis found that both current and former illicit drug abusers were significantly more likely to utilize outpatient mental health services compared to those without substance use disorders. As psychiatric disorders and substance use disorders commonly co-occur among those with HIV [1
] it is reasonable that those with current and/or a history of illicit drug abuse may be more likely to be referred and thereby utilize mental health services compared to those without substance use disorders. Finally, consistent with the HCSUS study, measures of disease status such as CD4 count and HIV-1 RNA were not associated with use of mental health outpatient services.[3
] Of note, we did not find any association between utilization of HAART and utilization of outpatient mental health services.
Similar to HCSUS data we found that those who were disabled were significantly more likely to utilize psychotropic medication as compared to those without disabilities.[2
] Also consistent with the HCSUS data[2
] we found that Blacks and Hispanics were less likely to report using psychotropic medications compared to Whites. Other studies have also found that African-Americans and Hispanics are less likely to use antidepressants for depression in primary care settings and HIV settings.[11
] Pooled results of randomized, placebo controlled clinical trials demonstrate that antidepressants are efficacious in treating depression among depressed HIV infected individuals. Blacks and Hispanics were underrepresented in the many of the studies limiting the generalizability of results to these groups of people. [15
] This possible disparity may be particularly important as depression is associated with poor adherence to HAART and several studies have found that mental health treatment increases the probability that individuals with depression receive and utilize HAART. [16
] Given this studies that more directly evaluate the efficacy of antidepressant treatments among Black and Hispanic HIV infected people are certainly warranted.
Unlike HCSUS, we found that women were significantly more likely to utilize psychotropic medication compared to men. This is similar to research that suggests that depressed women are more likely than depressed men to receive treatment for depression. [12
] Finally, measures of disease status such as CD4 count and HIV-1 RNA were not associated with use of psychotropic medications. We did not find any association between utilization of HAART and utilization of psychotropic medications.
We also found that increased use of primary care visits was associated with both greater use of outpatient mental health services and psychotropic medication. This finding may be consistent with previous studies that have found that the use of ancillary services, such as mental health services is associated with increased engagement and retention in primary care.[21
] This may also suggest the importance of integrating mental health and HIV related medical services in one location. By doing this, patients can receive attention to both their medical and mental health needs at one location which may limit barriers associated with transportation, child-care as well as competing demands on the patients time.
Results of this study should be interpreted in light of several potential limitations. First, we were limited by self-reported measures of outpatient psychiatric care utilization in this analysis. It is possible that some respondents forgot to include some outpatient psychiatry visits in the total, while others may have reported visits that occurred outside the six-month reference period. Though this may introduce misclassification bias, reliance on self-reported data greatly increases the feasibility of such studies. Second, the convenience sample of interviewees may introduce bias into the estimates of outpatient psychiatric care use, as respondents and non-respondents may differ in service use. Unlike Burnam et al. we did not have a method for identifying need for psychiatric services. Nonetheless, our results are similar to Burnam even after they controlled for need for psychiatric services.[3
Due to the cross sectional nature of our study we can not make any claims about the direction of causation. The HIVRN is not a national probability sample. Though its population is similar to that of a 1996 nationally representative sample of persons in care for HIV infection,[23
]we are cautious about generalizing our findings to the entire U.S. HIV-infected population. In particular, all subjects in this study were engaged with a source of regular HIV care. We compared all patients enrolled in the HIVRN during 2003 to those who participated in the interview and found no differences in gender, race, or HIV risk factor; however, there may still be other differences between those patients who chose to participate in the study and the overall population of patients using HIVRN clinics. The high percentage of interviewees who were unemployed, disabled, or retired may also have led to the introduction of bias, as these patients had more potential free time to attend an interview. Although participants were specifically asked about psychotropic medication used to treat mental or emotional problems, it is possible that participants may have reported using these medications to treat somatic problems [e.g., pain). This may bias our results leading to an over-estimation of use of these medications. Although changes in HIV treatment have occurred since 2003 including the introduction of streamlined HAART treatments, novel classes of antiretroviral therapy (e.g., integrases) and a better understanding of HIV virus resistance patterns, few novel antidepressants or antipsychotic medications have been introduced into the American market over that time period. In fact, the most recent data regarding the use of mental health services in the United States was collected in 2001-2003, [24
] during the similar time of our study. It is unclear what impact these changes in the mental health system may have for our results. However, there is no data to our knowledge that suggests that their have been improvements in ultization of mental health services for minorities from 2003 to the present.