Diagnosis of Depression: Differentiating Depression and Adjustment Disorder

Depressive symptoms are common in HIV-infected patients. In a 1991 survey of patients presenting to the Johns Hopkins HIV clinic for their first medical visit, the AIDS Psychiatry Service found that 54% of patients had Axis I (nonsubstance abuse) psychiatric disorders, including 20% with major depression and 18% with depressive symptoms associated with adjustment disorder (Lyketsos et al, Int J Psychiatry Med, 1994). The epidemic nature of HIV disease in the arena of psychiatric practice is indicated by these and other findings in this survey. In particular, 74% of HIV-infected patients had a substance use disorder, 18% had cognitive impairment, and 27% had a personality disorder. Practitioners in HIV clinics have long anticipated the need for counseling services at the time of diagnosis and for ongoing mental health support as the disease progressed. At the beginning of the HIV epidemic, when the prognosis of the disease was especially grim and most patients died within 18 months of their diagnosis, there was a high degree of practitioner burnout since little more than palliative care could be offered. Although the advent of potent antiretroviral therapy has allowed patients a substantial increase in life expectancy, depressive symptoms are still extremely common. Depressive symptoms may lead patients toward higher-risk behavior, such as injection drug use (McDermott et al, Hosp Community Psychiatry, 1994), and may contribute to nonadherence to medical therapies (Singh et al, AIDS Care, 1996). In effect, depression may lead patients to become HIV-infected, concentrating a high proportion of depressed patients in the HIV clinic, and may then lead those patients to be nonadherent to antiretroviral therapy or therapy for opportunistic infections, resulting in a sicker population of patients at the clinic. Sicker patients are more demoralized by their sickness, which may worsen depression. A vicious cycle is thus perpetuated (Figure 1). Depressed HIV-infected patients may also be more likely to engage in behaviors that put others at risk of HIV infection. Important goals of treating depression in the HIV-infected patient thus include removing barriers to HIV disease treatment adherence and reducing the risk of transmission of infection, in addition to improving other aspects of function and quality of life for the individual patient.