The Impact of DSMIV Mental Disorders on Adherence

Authors: Sandra A Springer Azem Dushaj Marwan M Azar

Publish Date: 2012/05/30

Volume: 16, Issue: 8, Pages: 2119-2143

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Abstract

This is a systematic review of eightytwo published studies investigating the impact of DSMIV mental disorders on combination antiretroviral therapy cART adherence and persistence among persons living with HIV/AIDS PLWHA Sixtytwo articles examined depression with 58  N = 32/62 finding lower cART adherence and persistence Seventeen articles examined one or more anxiety disorders with the majority finding no association with cART adherence or persistence Eighty percent of the studies that evaluated the impact of psychotic N = 3 bipolar N = 5 and personality disorders N = 2 on cART adherence and persistence also found no association Seven out of the nine studies 78  evaluating the impact of antidepressant treatment ADT on cART adherence found improvement Adherence and depression measurements varied significantly in studies common research measurements would improve data harmonization More research specifically addressing the impact of other mental disorders besides depression on cART adherence and RCTs evaluating ADT on cART adherence are also neededCombination antiretroviral therapy cART has greatly improved the morbidity and decreased the mortality associated with HIV infection 1 2 3 The benefits of cART however are typically contingent upon excellent cART adherence and persistence in order to achieve suppression of HIV1 RNA levels and an increase in CD4 T cell lymphocytes 4 5 Suboptimal adherence to cART is strongly related to viral proliferation 6 7 drug resistance 7 8 disease progression 9 and death 3 Factors that can impair adherence to cART include drug addiction 10 11 12 alcohol use disorders 11 13 low socioeconomic status 14 social stigma 15 16 17 neurocognitive disorders 18 and mental disorders 19 When combined mental disorders and substance use disorders among persons living with HIV/AIDS PLWHA synergistically increase mortality via impairing adherence to cART 20Mental disorders include a variety of psychiatric conditions and are defined by the fourth Diagnostic Manual of Mental Disorders DSMIV 21 as ‘a clinically significant behavioral or psychological impairment of an individual’s normal cognitive emotional or behavioral functioning associated with present distress and caused by physiological or psychosocial factors’ Mental disorders are more common among PLWHA 63  as compared to the HIVnegative population 305  19 22 In a recently published study HIVpositive men were more likely to have any mood disorder odds ratio OR = 610 major depressive disorder/dysthymia OR = 377 any anxiety disorder OR = 402 and any personality disorder OR = 250 when compared to their HIVnegative samesex counterparts 23 In another study an estimated 60  of PLWHA receiving care in North Carolina had comorbid mental disorder symptoms 24The mental disorder most commonly associated with HIV infection is major depressive disorder MDD 25 with a prevalence ranging from 162  26 to 36  25 This is a four to sevenfold greater prevalence than in the general population 49  27 The large variation in prevalence rates of mental disorders has been partially attributed to differences in the specificity and sensitivity of the study instruments used 28 Mental disorders have been associated with decreased adherence to cART and impaired HIV virologic control in several studies 14 29 30 31 32 33 34 35 36 In one longitudinal study HIVpositive mothers with comorbid mental disorders were approximately six times more likely to die than adherent participants with no depressive symptoms 32 A recently published metaanalysis of 95 independent studies of PLWHA with depressive disorders concluded that depression was significantly associated with nonadherence to cART r = 019 95  CI = 014–025 p  00001 37 This metaanalysis however was not a systematic review of the studies of depression and adherence to cART To the authors’ knowledge there has not yet been a systematic review of studies published in the English literature evaluating all major Axis I and II DSMIV mental disorders on cART adherence and persistence among adult PLWHAThe specific aim of this paper is to therefore systematically review studies evaluating the impact of all of major Axis I and II DSMIV mental disorders excluding substance use disorders on combination antiretroviral adherence and persistence among PLWHA Though major depression is the principal focus of this review due to its higher prevalence other mental disorders such as anxiety and psychotic disorders will also be examined as they have also been reported to negatively impact participant adherence 34 38PubMed Scopus and Web of Knowledge were queried for peerreviewed original human research papers published in English from 1996 to December 2011 Google Scholar was also reviewed for details full text and additional articles The search for this systematic review took place from November 2010 to December 2011 Keywords and their combinations used in the search are available in an online appendix Papers were included if they were conducted in other countries outside of the United States given the high prevalence of mental disorders among PLWHA throughout the world

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