Ascertainment of HIV infected patients by this registry has been shown to be at least 95% complete. The HIV registry contains information on patient demographics , HIV transmission risk group , dates of known HIV infection, and AIDS diagnoses. KPNC also maintains complete and historical electronic databases on hospital admission/discharge/transfer data, prescription dispensing, outpatient visits, and laboratory tests results, including CD4 T-cell counts and HIV-1 RNA levels. Mortality information including date and cause of death are obtained from hospitalization records, membership files, California death certificates, and Social Security Administration databases. Mortality data were complete through December 31, 2007. Antiretroviral medication prescription data were obtained from KPNC pharmacy databases. Approximately 97% of members fill their prescriptions at KPNC pharmacies, including patients whose prescriptions are obtained through the Ryan White AIDS Drug Assistance Program. ARV medication data included date of first fill, dosage, and days supply, as well as data on all refills. Patients were classified as: currently receiving combination-ARV , current dual NNRTI/NRTI ARV use, past ARV use, or never users.Psychiatric diagnoses were assigned by providers.Psychiatric diagnoses selected for this study were the most common and serious psychiatric disorders diagnosed among health plan members including schizophrenic disorders , major depressive disorder, bipolar affective disorder, neurotic disorders , hysteria, phobic disorders, obsessive-compulsive disorder, anorexianervosa, and bulimia. We examined the impact of having one or more of these psychiatric disorders in aggregate, as in prior HIV studies.Within the health plan,rolling benches canada psychiatry can be accessed directly by patients. Mild cases of depression and anxiety may be addressed in primary care with medication but moderate to severe cases are referred to psychiatry.
Treatment in psychiatry includes assessment, psychotherapy and medication management. Patients diagnosed with a psychiatric disorder generally return to psychiatry for individual and/or group psychotherapy and/or medication evaluations. Our measure of psychiatric treatment was whether or not a patient had visits to a psychiatric clinic after a psychiatric diagnosis,obtained from automated databases.A diagnosis of ICD-9 substance dependence or abuse can be made by the patient’s clinician in primary care, SU disorder treatment, or psychiatry as a primary or secondary diagnosis.Diagnostic categories include all alcoholic psychoses, drug psychoses, alcohol dependence syndrome, drug dependence , alcohol abuse, cannabis abuse, hallucinogen abuse, barbiturate abuse, sedative/tranquilizer abuse, opioid abuse, cocaine abuse, and amphetamine abuse; as well as multiple substance abuse and unspecified substance abuse. In our analyses we classified patients as having one or more diagnoses of substance abuse and/or dependence versus no diagnosis.KPNC provides comprehensive outpatient SU treatment available to all members of the health plan. Services include both day hospital and traditional outpatient programs,both of which include eight weeks of individual and group therapy, education, relapse prevention, family therapy, with aftercare visits once a week for ten months. In addition to these primary services, ambulatory detoxification and residential services are available, as needed. A small proportion of patients engage in residential SU treatment, conducted by contractual agreement with outside institutions. These data are available in the KPNC referrals and claims databases. As with psychiatric treatment, in the current study SU treatment initiation was measured as having one or more visits to an outpatient program or a stay in a residential SU treatment unit following diagnosis.Analyses focused on diagnoses of psychiatric disorders with and without co-occurring SU diagnoses as the primary predictors of interest. The distribution of demographic, clinical and behavioral characteristics was compared between patients with and without a major psychiatric diagnosis; statistical significance was assessed using the w2 test.
The distribution of cause of death was examined by psychiatric diagnostic status ; statistical significance was assessed using the w2 test or Fisher’s exact test where table cells were sparsely populated. Cox proportional hazards regression was used to obtain point and interval estimates of mortality relative hazards associated with psychiatric diagnosis/treatment status and SU problems diagnosis/treatment status, with each of these two time dependent covariates measured at three levels: no diagnosis, diagnosis with treatment, diagnosis without treatment. With the goal of examining the joint effects of these two covariates on mortality, results are expressed as hazard ratios for combi nations of psychiatric diagnosis/treatment and SU diagnosis/treatment levels, with no diagnosis of either comorbidity as the referent. These estimates were adjusted for an a priori chosen set of available covariates, including age at entry into study, race/ethnicity, gender, HIV transmission risk group, CD4 T-cell counts and HIV RNA levels and ARV treatment modeled as time-dependent covariates, year of known HIV infection, AIDS diagnosis prior to entry into study, and evidence of hepatitis C viral infection. Initial modeling results demonstrated a significant interaction be tween psychiatric and SU diagnosis/treatment status in Cox regression models. Therefore, relative hazard estimates of interest were obtained via appropriate linear combinations of parameter estimates from a fully saturated model. Although a significant minority of patients remained ARV naı¨ve throughout the study follow-up,flood table we wanted to estimate adherence to combination highly active antiretroviral therapy stratified by psychiatric diagnosis and SU diagnosis status for study participants who did receive HAART. Adherence was measured using electronic pharmacy dispensing refill records; the “days supply of HAART medication was divided by the “total time elapsed between first day of HAART initiation and last day of HAART medication supply’’ over the first 12 and 24 months of study follow-up. Mean and standard deviaition of adherence were then estimated by diagnostic status category.
All data analyses were conducted using SAS software, version 9.1.The distributions of demographic and HIV-related clinical and behavioral characteristics by psychiatric diagnosis status are presented in Table 1. The results of w2 tests indicate significant differences in most characteristics between those patients with and without a psychiatric diagnosis. However it can be seen that the categories of these characteristics were still very similar in distribution in both groups. Finding significant results for very small differences in distributions is likely the consequence of having a very large sample size in this study. The majority of patients were white, male, 30–49 years of age at baseline, and belonged to the men who have sex with men HIV transmission risk group. CD4 T lymphocyte cell counts measured at or near time of study entry were comparable in both patients with and without a psychiatric diagnosis. Similar results were observed for HIV RNA levels. Of the 2472 patients with a psychiatric diagnosis, 83.9% had one or more psychiatry department visits. The proportion of patients with any ARV therapy experience at baseline was similar across psychiatric disorder status, with on average 35% of all patients having no ARV experience. Throughout study follow-up, approximately 25% of all patients remained ARV naı¨ve. Among those who were receiving HAART during study follow-up, mean adherence was estimated as 82.4% among patients with a psychiatric diagnosis at 12 months after initiation of HAART and 83.7% among patients with no psychiatric diagnoses; similar mean adherence was observed at 24 months. Patients diagnosed with SU problems showed mean adherence of 81.1% at 12 months after initiating HAART in comparison to 83.5% among patient without a SU problem diagnosis. Because adherence rates were similar across diagnostic status, we did not conduct a subanalysis of ARV-experienced patients only, where adherence would have been included as a covariate in the regression model. The distribution of cause of death cross-tabulated by psy chiatric diagnosis is presented in Table 2. The majority of deaths among patients with or without a psychiatric diagnosis were attributed to HIV/AIDS. The remaining causes of death had proportionately the same distribution across categories of psychiatric diagnosis status, with the possible exception of suicide which was twice as common among patients with a psychiatric diagnosis in comparison to pa tients with no diagnosis. Examining all-cause mortality for the entire study follow-up, we found an age-adjusted mortality rate of 28.6 deaths per 1000 person–years for patients with a psychiatric diagnosis versus 17.5 deaths for those with out a psychiatric diagnosis. To examine the joint effects of psychiatric diagnosis, psychiatric treatment visits, SU diagnosis, and SU treatment on mortality, relative hazards were estimated using Cox proportional hazards regression. As mentioned in Statistical methods, the effects of psychiatric diagnosis/treatment and SU diagnosis/treatment were not additive, with statistically significant interactions between these covariates.
RHs and 95% Confidence Intervals estimated from unadjusted and adjusted models are presented in Table 3. Categories of diagnosis and treatment are ordered from lowest to highest RH in the unadjusted model 1. In comparison to patients with neither a psychiatric diagnosis nor a SU diagnosis , the highest risk of dying was found among patients with dual diagnoses but who had no psychiatric treatment visits and no SU treatment. This effect was somewhat attenuated after adjustment for potential confounders but remained statistically significant. Similar results were observed for patients who had a psychiatric diagnosis but no psychiatric services and no SU diagnosis that were very similar to those parameter estimates in model 2.During 12 years of follow-up , we observed a higher mortality risk for HIV-infected patients diagnosed with both psychiatric and SU disorders in comparison to patients with neither diagnosis. However, we observed that psychiatric and SU treatment, in general, reduced mortality risk in single and dual diagnosed patients, and remained statistically significant even after adjustment for age, race, immune status, HIV viral load, antiretroviral therapy use, and other potential confounders. Accessing psychiatric treatment reduced mortality risk among dual diagnosed patients who were treated or not treated for SU disorder. Previous studies of individuals with HIV infection have found that those with psychiatric disorders are at elevated risk for poor medication adherence and clinical outcomes.There is substantial evidence that depression, stressful life events and trauma affect HIV disease progression and mortality.This effect has been found even controlling for medication adherence, in a study that showed that HAART adherent patients with depressive symptoms were 5.90 times more likely to die than adherent patients with no depressive symptoms.Depressive symptoms in dependently predicted mortality among women with HIV,18 and also in a separate study of men.17 Similarly, in multi variate analyses controlling for clinical characteristics and treatment, women with chronic depressive symptoms were 2 times more likely to die than women with limited or no depressive symptoms.Among women with CD4 cell counts of less than 200 10/ L, HIV-related mortality rates were 54% for those with chronic depressive symptoms and 48% for those with intermittent depressive symptoms compared with 21% for those with limited or no depressive symptoms. Chronic depressive symptoms were also associated with significantly greater decline in CD4 cell counts after controlling for other variables.These mechanisms could help to explain the greater risk of mortality ob served in our sample. Our findings strongly highlight the importance of access to psychiatric and SU disorder treatment for this population. It was estimated that during a 6-month period, 61.4% of 231,400 adults in the United States receiving treatment for HIV/AIDS used psychiatric or SU disorder treatment services.A significant number of HIV-infected patients report accessing psychiatric services.Such visits are associated with decreased risk of discontinuing HAART.Burnam et al.found that those with less severe HIV-related illness were less likely to access psychiatric or SU disorder treatment. One study found that engagement in SU disorder treatment was not associated with a decrease in hospital use by HIV-infected individuals with a history of alcohol problems.Improvement in depression was associated with increase in HAART adherence among injection drug users.A limitation of our study may have been the differences in timing of the psychiatric diagnosis and/or SU diagnosis. Some patients in our sample may have received their psychiatric diagnosis shortly after the onset of symptoms or in the initial phase of substance dependence or abuse, while other patients may have been diagnosed at a more advanced stage. Some patients may have met the criteria for a psychiatric or SU diagnosis without receiving one. In addition, some study subjects may have received psychiatric care or informal SU disorder services or self-pay services outside of the KPNC health plan, and our study does not have information about those services. We also could not control for level of comorbidity for other diseases and conditions at baseline, because many patients had insufficient health plan membership time prior to study entry. This study examined mortality among HIV-infected patients with private health insurance who received medical care in an integrated health plan, who had full access to psychiatric and SU disorder services, and who had received diagnoses of psychiatric disorder and substance dependence or abuse by a clinician.