Psychiatric Comorbidity Among Hospitalized AIDS Patients vs. Non-AIDS Patients Referred for Psychiatric Consultation

Psychiatric Comorbidity Among Hospitalized AIDS Patients vs. Non-AIDS Patients Referred for Psychiatric Consultation A. BIALER, M.D., JOEL 1. WALLACK, M.D. L. PRENZLAUER, M.D., LISA BOODONOFF, M.D.

PHILIP STEVEN

ILENE WILETS, PH.D.

Data were collected on 3,420 psychiatric consultations from July I, 1989, to January I. 1994, of which 675 were for patients identified as infected with the human immunodeficiency virus (HIV). Comparisons ofpsychiatric comorbidity among persons with AIDS (PWAs), HIV+ asymptomatic patients, and non-HIV patients were made. Dementia was a significantly frequent comorbid diagnosis among the referred PWAs compared with the general consultation population and was related to older age. Psychiatric comorbidity among the referred HIV+ asymptomatic patients more closely resembled the general consultation population. Major depression was relatively rare among the PWAs. The authors believe that the large sample size of this study allows for an accurate representation of the psychiatric disorders found among medically ill HIV patients in an urban hospital who are referredfor psychiatric consultation. (Psychosomatics 1996; 37:469-475)

W

elI into the second decade of the AIDS epidemic, a cumulative total of more than 440,000 cases of AIDS have been reported in the United States through 1994.' A substantial number of papers and abstracts have been published reporting the incidence and prevalence of psychiatric disorders among patients infected with HIY. 2-5 The neuropsychiatric manifestations of AIDS have also been welI described and documented.6-8 Most studies, however, have focused on outpatient populations and/or cohorts constituted primarily of gay and bisexual men. The results of these studies may not be relevant to the rapidly increasing numbers of women and men infected with HIV through injecting druguse behavior and heterosexual contact. This study was undertaken to identify the 9 prevalence of DSM-III-R psychiatric disorders among patients with symptomatic HIV disease VOLUME 37 • NUMBER 5 • SEPTEMBER - OCTOBER 1996

(PWAs) who were referred for inpatient psychiatric consultation at Beth Israel Medical Center (BIMC), a 970-bed, tertiary-care, teaching hospital, and a New York State-designated AIDS center located in the lower East Side of Manhattan. The daily census of inpatients with HIVrelated disorders is approximately 70. Table I illustrates the demographic makeup of the HIV inpatients folIowed by the hospital's AIDS Received February 3. 1995; revised March 24. 1995; accepted July 7. 1995. From the Division of ConsulllltionLiaison Psychiatry and Behavioral Medicine, Beth Israel Medical Center. and The Albert Einstein College of Medicine. New York; and the Department of Psychiatry. Bellevue Hospillli Center. and the New York University School of Medicine. New York. Address reprint requests to Dr. Bialer. Beth Israel Medical Center. 317 East 17th Street. Fiennan Hall. Suite 509. New York. NY 10003. Copyright © 1996 The Academy of Psychosomatic Medicine.

469

Psychiatric Comorbidity: AIDS

VS.

Non-AIDS Patients

program during the time of the study (19891994). Although the demographics of our medical center's HIV population differ from the national averages, they are fairly representative for the New York metropolitan area. This study also sought to determine if the psychiatric problems of referred hospitalized PWAs were similar or different from those of HIV-seropositive, asymptomatic inpatients. In addition, differences and similarities in psychiatric comorbidity among all referred HIV inpatients were compared with the general non-HIV-infected hospitalized population seen for psychiatric consultation. METHODS Requests for psychiatric consultations at BIMC are initiated and ordered by the patient's primary physician. Consultations are then done by psychiatric residents assigned to the Consultation-Liaison (C-L) Service, C-L fellows, or C-L attending staff. In addition to the traditional chart note consultation, all consultants record demographic data, psychiatric and medical diagnoses, treatment recommendations, and final disposition of the patient on the MICR0-CARES Consortium Psychiatric Consultation Questionnaire,tO a scannable computer database form. The consultants received extensive training in the use of the MICRO-CARES database system and were provided with a standard instruction manual and glossary. The MICRO-CARES questionnaire is a tool for recording information after a diagnosis is made and does not influence the clinician's evaluation or diagnostic approach. The diagnoses were based on the clinical evaluations of the consultants and determined by DSM-III-R criteria under the supervision of attending psychiatrists. Finally, all data collected by the consultants were reviewed by the authors to assure accuracy and adherence to glossary definitions before data entry into the MICRO-CARES program. Although the authors participated in sessions to determine interrater reliability in the completion of the MICRO-CARES form, the interrater reliability of diagnoses in this study was not specifically determined. 470

From July I, 1989, to January I, 1994, data were collected and entered on a total of 3,420 inpatient psychiatric consultations. Of these, 675 (19.7%) were patients identified as infected with HIY. The MICRO-CARES system allows for the recording of provisional diagnoses, but only those patients with confirmed diagnoses meeting full DSM-III-R criteria were included in the determination of the prevalence of psychiatric comorbidity. "No Axis I diagnosis" and "No Axis II diagnosis" were included as confirmed diagnoses. Unconfirmed diagnoses were most often a result of discharge before the completion of the evaluation. The patients with symptomatic HIV disease (1987 Centers for Disease Control and Prevention [CDC] stage 4," and 1993 CDC stages A3, B, and C t2 ) were compared with the asymptomatic HIV + patients; both of these groups were also compared with a group of non-HIV patients, adjusted for age less than 60 years old. Data were analyzed with Epi Info, Version 5. 13 Differences between study groups on continuous variables were assessed by the Students' unpaired I-test and analysis of TABLE I.

Inpatient demographics of patients en· rolled in AIDS program: July I, 1989January I, 1994'

(N=3,007) %

Characteristic Men Women White African American Hispanic Other Gaylbisellual IVDU Heterosellual ellposure Other Unknown risk AIDS/symptomatic HIV Asymptomatic

=

78.6 21.4 29.7 26.0 39.5 4.8 30.2 44.9 8.8 4.9 6.2 84.5 15.5

=

Note: IVDU intravenous drug user; AIDS acquired immunodeficiency syndrome; HIV human immunodeficiency virus. IAge ± SO 38.6 ± 9.3 years.

=

=

PSYCHOSOMATICS

Bialer et al.

variance (ANOVA) techniques. The chi-square test was used to evaluate differences between demographic categories with respect to the presence or absence of psychiatric disorders. Findings were considered as statistically significant with a P-value of less than 0.05. RESULTS Of the initial 2,745 evaluated non-HIV patients, 1,849 were included by age criteria; confirmed diagnoses were made for 1,562 (84.5%). Confirmed diagnoses were made for 549 (81 %) of the 675 PWA and HIV + patients. The demographics of the three groups are displayed in Table 2. By design, the three groups

were matched by age. Information on educationallevel and employment status was not collected during the first 18 months of the study, resulting in smaller sample sizes for these sets of statistics. Women were underrepresented among the HIV patients (especially those with AIDS). and those of Hispanic ethnicity were underrepresented among the general population. Although there were some differences among the groups, it is interesting to note that the majority of our entire sample were single or divorced/separated. less than 20% were married, and few, even among those infected with HIV, were widowed. There was a higher frequency of unemployment among the HIV + patients and a higher frequency of disability among the PWAs.

Demographics 01 study population

TABLE 2.

PWA (n 433)

HIV+ (n 116)

Non-HIV (n 1,562)

=

=

37.5 ± 7.7

36.3 ± 7.6

38.3 ± 10.2

NS

Gender Male,n(%) Female. n (%)

325 (75) 108 (25)

78(67) 38 (33)

906 (58) 656 (42)

P
Race White African American Hispanic Other

131 (3\) 109(25) 182 (42) 8 (2)

21 (18) 44 (38) 50 (43) I (I)

527 (34) 435 (28) 529 (34) 47 (3)

P
Marital status Single Married Divorced/separated Widowed Other/unknown

224 (52) 73 (17) 72 (17) 13 (3) 46 (II)

60(52) 15 (13) 24 (2\) 6 (5) II (10)

718 (47) 288 (19) 348 (23) 41 (3) 157 (8.7)

P<0.05 NS P<0.05 NS NS

Employment Working Unemployed Disabled Other

(n 277) 18 (7) 102 (37) 127 (46) 30 (10)

(n 72) 5 (7) 39 (54) 21 (30) 7 (10)

=

(n 1,025) 135 (13) 497 (48) 270 (26) 123(13)

Education College graduate H.S. graduate < 12 years < 7 years Unknown

(n 269) 19 (7) 74 (19) 58 (22) 15 (6) 103 (38)

=

(n 1,011) 109 (I \) 308 (31) 264 (26) 63(6) 267 (31)

Age, mean

Note:

± SD

=

PWA

=

=

(n 72) 3(4) 17 (24) 20 (28) 3 (4) 29 (40)

=

P
=

P<0.05 NS NS NS P
=persons with AIDS; HIV =human immunodeficiency syndrome; NS =not significant.

VOLUME 37. NUMBER 5. SEPTEMBER - OCTOBER 1996

471

Psychiatric Comorbidity: AIDS

VS.

Non-AIDS Patients

The noninfected sample appeared to have had more years of education. The prevalence of psychiatric disorders and comparisons among the PWAs, HIV+ asymptomatic, and non-HIV patients are reported in Tables 3,4, and 5. All psychiatric diagnoses are reported according to DSM-III-R criteria and terminology. One should note, however, that DSM-IV no longer uses the term "organic mental disorders" but instead describes these disorders as either "due to a general medical condition" or "substance- induced." The psychiatric diagnoses in the following discussion may refer to "organic mental syndromes," "organic mood disorders," or "deliria," which include the current DSM-IV general medical and substance-induced etiologies. As can be seen in Table 3, the diagnosis of dementia was strikingly more frequent among the PWAs compared with the noninfected patients (22.4% vs. 3.9%, P < 0.01). Diagnoses of substance use disorder, major depression, and personality disorder were significantly more frequent among the referred non-HIV population. There were no significant differences in the frequencies of the diagnoses of delirium, organic mood disorder, organic mental syndrome not otherwise specified (NOS), or adjustment disorder. TABLE 3.

Prevalence of psychiatric disorders: hospitalized PWAs vs. non-HIV patients PWA

Disorder

(n

Table 4 shows a comparison of psychiatric comorbidity among the PWAs vs. the HIV+ asymptomatic patients. According to the CDC case definition, the patients with AIDS dementia are not asymptomatic, and none of the patients in our asymptomatic sample were diagnosed with other types of dementia. Therefore, this diagnosis was not analyzed in this comparison. Once again, the prevalences of delirium, organic mood disorder, organic mental syndrome NOS, and adjustment disorder were not significantly different. However, diagnoses of substance use disorder and personality disorder were significantly more frequent among the HIV+ patients. Except for the diagnosis of major depression, which was also not significantly different between these two groups, the comparison of psychiatric comorbidity between the PWAs vs. the HIV+ asymptomatic patients appears similar to the comparison between the PWA vs. non-HIV groups in Table 3. Comorbidity among the asymptomatic HIV+ group closely resembled the general consultation population except for the prevalence of substance use disorder, which was extraordinarily high among the asymptomatic HIV+ patients (Table 5). TABLE 4.

Prevalence of psychiatric disorders: hospitalized PWAs vs. HIV+ asymptomalic patients PWA

Non-HiV

=433) (n =1,562)

P

Disorder

HIV+

(n =433) (n

=116)

P

Dementia

22.4%

3.9%

P
Dementia

22.4%

0

Delirium

28.9%

28.4%

NS

Delirium

28.9%

23.3%

NS

Organic mood disorder

12.9%

14.1%

NS

Organic mood disorder

12.9%

10.3%

NS

NS

Organic mental syndrome. not otherwise specified

9.5%

102.1%

NS

Adjustment disorder

13.2%

12.9%

NS

35.6%

63.0%

P
Organic mental syndrome. not otherwise specified

9.5%

10.5%

Adjustment disorder

13.2%

12.1%

NS

Substance use disorder

35.6%

46.4%

P
Substance use disorder

Major depression Personality disorder No diagnosis

=

1.4%

4.2%

P
Major depression

18.7%

24.4%

P<0.05

Personality disorder

1.0%

0.8%

NS

Note: PWA persons with AIDS; HIV = human immunodeficiency virus; NS = not significant.

472

No diagnosis

1.4%

1.7%

18.7%

31.9%

P
1.0%

0.9%

NS

NS

=

Note: PWA = persons with AIDS; HIV human immunodeficiency virus; NS = not significant.

PSYCHOSOMATICS

Bialer et al.

Finally. the PWAs diagnosed with dementia were significantly older than those who did not receive this diagnosis (mean age ± SO =39.5 ± 8.3 vs. 36.9 ± 7.4. F = 8.376. P = 0.004). In addition. we found the prevalence of dementia in the PWA sample to remain stable over the course of the study (1989: 20.1 %. 1990: 22.5%. 1991: 22%. 1992: 21.6%. and 1993: 23.1 %). No other meaningful relationships between the presence of a specific psychiatric disorder and any of the demographic variables were noted. DISCUSSION There have been few published reports of the psychiatric comorbidity of hospitalized HIV patients. and among these studies the sample sizes have usually been quite small. For example. one study reported on the findings of only 13 inpatient psychiatric consultations. IS making any meaningful comparisons with our study impossible. Almost 10 years ago. before much was known about the neuropsychiatric manifestations of AIDS. Perry and Tross reported on their retrospective chart review of 52 AIDS inpatients. 16 In contrast to our results. they found mood disturbance. diagnosed in 82.7% of the TABLE 5.

Prevalence of psychiatric disorders: hospitalized HIV+ asymptomatic patients vs. non-HIV patients HIV (n

Non-HIV

=116) (n =1,562) 0

3.9%

Delirium Organic mood disorder

23.3% 10.3%

28.4% 14.1%

NS

Organic mental disorder. not otherwise specified

12.1%

10.5%

NS

Adjustment disorder

12.9%

12.1%

NS

Substance use disorder

63.0%

46.4%

P
Dementia

Major depression Personality disorder No diagnosis

Note: NS

HIV

NS

1.7%

4.2%

NS

31.9%

24.4%

NS

0.9%

0.8%

NS

=human immunodeficiency virus;

=not significant.

VOLUME 37. NUMBER 5. SEPTEMBER - OCTOBER 1996

sample. to be the most frequent psychiatric disorder. However. most of these patients received a diagnosis of "presumptive depression" because there was not enough information to make a definitive diagnosis. We suspect. based on our experience. that many of these patients had a mood disorder secondary to a medical or neurological condition. It should be noted that delirium (28.8%) and dementia (11.5%) were also quite frequent in their sample. Depressive illness (ICD-9) was also the most frequent diagnosis in a series of patients referred for consultation at a London hospital. 17 However. we question the validity of these authors' findings since there were confounding problems, including abnormal computed tomography scans, severe medical illness, and/or drug and alcohol use, in a large proportion of the sample. O'Dowd and McKegney reported on a study of 67 consultations with AIDS patients with a population demographically similar to 18 ours but with some differing results. Adjustment disorders were much more frequently diagnosed in their sample (range: 30%-40%) compared with ours (range: 12%-13%). We diagnosed substance use disorders and personality disorders more frequently. In both studies. dementia was significantly more frequent in the PWAs compared with the non-HiV patients. As both studies evaluated patients referred for consultation, the differences noted in diagnoses may reflect the varying reasons that consultations were requested at the respective institutions. thus resulting in different sample populations. Our finding that a diagnosis of dementia in PWAs was related to older age replicates the findings of others. 19 Despite the fact that some have suggested a decreasing incidence of AIDS dementia since the introduction of zidovudine (AZT) therapy,20 the frequency of this diagnosis in our study showed no such decline over time. While one may expect to find that dementia would be diagnosed more frequently among PWAs in a study population under the age of 60 years, the strikingly higher prevalence of this disorder compared with the non-HIV group in 473

Psychiatric Comorbidity: AIDS vs. Non-AIDS Patients

our study is remarkable. This may in part be attributable to a higher index of suspicion of dementia among PWAs compared with the general medically ill, but we believe our findings reflect the presence of a major comorbid problem particular to the HIV population. Baer has described the increased management problems and prolonged hospitalizations required for PWAs with dementia. 21 Empirically, the resulting loss in functioning, the effects on family members, and the increasing demands on the health care system caused by dementia in a relatively young population are immeasurable. It is also important to note that among the referred HIV+ asymptomatic patients, as in the general consultation population at our hospital, substance use disorders and personality disorders were significantly frequent comorbid diagnoses. We suspect that these disorders were directly related to the reason for hospitalization for many of these patients. Thus, in this relatively healthy population, the comorbid diagnosis of substance use disorder and also personality disorder had a major impact, requiring additional psychiatric attention and expertise. It is interesting to note the high prevalence of substance use disorders found among the general population. This incidence may reflect the demographics of patients admitted to our institution or more likely reflect the reasons that patients were referred to the psychiatry consultation service. Also, the HIV serostatus for most patients in our general population sample was determined by history alone, and probably a small proportion of these patients were HIV-infected. This could account for some of the similarities found between the HIV+ and non-HIV groups. Large-scale studies of psychopathology among HIV outpatients have demonstrated significantly higher rates of mental disorders, particularly depression and substance use disorders, compared with the general population. 4 •s Our own previously reported work has shown that diagnoses of adjustment disorders, major depression, and personality disorders were more frequent among HIV outpatients, whereas organic mental disorders were more frequent among HIV inpatients, regardless of disease stage. 22 474

In the context of the current study of psychiatric comorbidity among HIV inpatients, we wish to emphasize the importance of the recognition of dementia in the patient with AIDS, as well as the equally important recognition of substance use disorder in the HIV+ asymptomatic patient. There were two main limitations to this study. First was the potential bias of the sample. The patients referred for psychiatric consultation may have prevalence rates of psychiatric comorbidity that are not generalizable to the entire hospitalized population. Also, the finding that DSM-III-R diagnoses were not confirmed in 15% of the patients evaluated may have caused a sample bias; if these patients could have been further evaluated the prevalence rates reported may have been altered. It should also be noted that 21 % of the HIV patients in our study were asymptomatic, compared with 15.5% of the AIDS program inpatients. However, the AIDS program at our hospital does not routinely enroll all asymptomatic patients, and our sample more accurately reflects the background inpatient population. The second limitation ofour study regards the reliability and validity of the diagnoses. As stated in the methods section, interrater reliability was not determined for this study. In addition, diagnoses were based on clinical evaluations rather than structured interviews. However, the authors, who determined the final diagnoses for all of the patients in the study, adhered strictly to DSM-III-R criteria given the available information. A study to determine the reliability and validity of the psychiatric diagnoses of patients evaluated by the consultation service is now in progress. Given these limitations, we believe that the relatively large sample size provides an accurate representation of psychiatric comorbidity among referred patients at our hospital and that these results may be generalizable to other hospitals in urban settings. We found that I) dementia was a significantly frequent comorbid diagnosis among the AIDS patients compared with the general population, 2) the diagnosis of dementia among the PWAs was related to older PSYCHOSOMATICS

Bialer el al.

age, 3) psychiatric comorbidity among the HIV+ asymptomatic patients more closely resembled the general hospitalized population, and 4) major depression was relatively rare among the PWAs compared with the general population. Large-scale studies of psychiatric comorbidity among all hospitalized HIV pa-

tients are required to characterize the psychiatric problems of this population accurately.

See the related article. an editorial by Constantine G. Lyketos. M.D., and Glen J. Treisman. M.D.. Ph.D., on pages 407-412 of this issue.

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panded surveillance case definition for AIDS among adolescents and adults. MMWR CDC Mom Monal WkIy Rep 1992; 41: 1-19 13. Dean AG, Dean JA, Bunon AH. et al: Epi Info. version 5: a word processing, database, and statistical program for epidemiology on microcomputers. Stone Mountain, GA. USD, Inc.. 1990 14. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association. 1994 IS. Dilley JW. Ochitill HN, Perl M, et al: Findings in psychiatric consultations with patients with acquired immune deficiency syndrome. Am J Psychiatry 1985; 142:82-85 16. Perry SW, Tross S: Psychiatric problems of AIDS inpatients at the New York Hospital: preliminary repon. Public Health Rep 1984; 99:200-205 17. Seth R, Granville-Grossman K, Goldmeier D. et al: Psychiatric illnesses in patients with HIV infection and AIDS referred to the liaison psychiatrist. Br J Psychiatry 1991; 159:347-350 18. O'Dowd MA. McKegney FP: AIDS patients compared with others seen in psychiatric consultation. Gen Hosp Psychiatry 1990; 12:50-55 19. Janssen RS, Nwanyanwu OC. Selik RM, et al: Epidemiology of human immunodeficiency virus encephalopathy in the United States. Neurology 1992; 42:1472-1476 20. Ponegies P. Enting RH. de Gans J, et al: Presentation and course of AIDS dementia complex: 10 years offollow-up in Amsterdam, the Netherlands. AIDS 1993; 7:669-675 21. Baer JW: Study of 60 patients with AIDS or AIDS-related complex requiring psychiatric hospitalization. Am J Psychiatry 1989; 146:1285-1288 22. Prenzlauer SL. Bialer PA, BogdonoffL, et al: Psychiatric disorders in HIV patients: hospitalized vs. non-hospitalized. Paper presented in the Abstracts of the Tenth International Conference on AIDS, PBOI97. Yokohama, Japan, 1994

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