Sexual minorities are at increased risk for multiple mental health burdens compared with heterosexuals. The field has identified 2 distinct determinants of this risk, including group-specific minority stressors and general psychological processes that are common across sexual orientations. The goal of the present article is to develop a theoretical framework that integrates the important insights from these literatures. The framework postulates that (a) sexual minorities confront increased stress exposure resulting from stigma; (b) this stigma-related stress creates elevations in general emotion dysregulation, social/interpersonal problems, and cognitive processes conferring risk for psychopathology; and (c) these processes in turn mediate the relationship between stigma-related stress and psychopathology. It is argued that this framework can, theoretically, illuminate how stigma adversely affects mental health and, practically, inform clinical interventions. Evidence for the predictive validity of this framework is reviewed, with particular attention paid to illustrative examples from research on depression, anxiety, and alcohol-use disorders.

How does sexual minority stigma “get under the skin”? A psychological mediation framework.

Background: There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders. Subjects and Methods: We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses. Results: Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder. Conclusions: Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/205826/yoa9450.pdf

Psychiatric Disorders and Drug Use Among Human Immunodeficiency Virus–Infected Adults in the United States

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Substance abuse treatment.

Mood disorders in the medically ill: scientific review and recommendations.

ContextThe impact of depression on morbidity and mortality among women with
human immunodeficiency virus (HIV) has not been examined despite the fact
that women with HIV have substantially higher rates of depression than their
male counterparts.ObjectiveTo determine the association of depressive symptoms with HIV-related
mortality and decline in CD4 lymphocyte counts among women with HIV.DesignThe HIV Epidemiologic Research Study, a prospective, longitudinal cohort
study conducted from April 1993 through January 1995, with follow-up through
March 2000.SettingFour academic medical centers in Baltimore, Md; Bronx, NY; Providence,
RI; and Detroit, Mich.ParticipantsA total of 765 HIV-seropositive women aged 16 to 55 years.Main Outcome MeasuresHIV-related mortality and CD4 cell count slope decline over a maximum
of 7 years, compared among women with limited or no depressive symptoms, intermittent
depressive symptoms, or chronic depressive symptoms, as measured using the
self-report Center for Epidemiologic Studies Depression Scale.ResultsIn multivariate analyses controlling for clinical, treatment, and other
factors, women with chronic depressive symptoms were 2 times more likely to
die than women with limited or no depressive symptoms (relative risk [RR],
2.0; 95% confidence interval [CI], 1.0-3.8). Among women with CD4 cell counts
of less than 200 × 106/L, HIV-related mortality rates were
54% for those with chronic depressive symptoms (RR, 4.3; 95% CI, 1.6-11.6)
and 48% for those with intermittent depressive symptoms (RR, 3.5; 95% CI,
1.1-10.5) 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 in the model,
especially among women with baseline CD4 cell counts of less than 500 ×
106/L and baseline viral load greater than 10 000 copies/µL.ConclusionsOur results indicate that depressive symptoms among women with HIV are
associated with HIV disease progression, controlling for clinical, substance
use, and sociodemographic characteristics. These results highlight the importance
of adequate diagnosis and treatment of depression among women with HIV. Further
research is needed to determine if treatment of depression can not only enhance
the mental health of women with HIV but also impede disease progression and
mortality.

https://jamanetwork.com/journals/jama/articlepdf/193662/joc01588.pdf

Mortality, CD4 Cell Count Decline, and Depressive Symptoms Among HIV-Seropositive Women: Longitudinal Analysis From the HIV Epidemiology Research Study

Objective. —To investigate whether high levels of depressive symptomatology at baseline predict more rapid decline of CD4 lymphocyte counts and progression of clinical disease in persons infected with the human immunodeficiency virus (HIV). Design. —Prospective cohort study with semiannual data collection waves and up to 66 months of follow-up. Setting. —Population-based probability sample of single men in areas of San Francisco with high case rates of the acquired immunodeficiency syndrome (AIDS). Subjects. —All 330 homosexual or bisexual men who by January 1985 had serological evidence of HIV infection but had not had an AIDS diagnosis. Analysis of CD4 lymphocyte change was performed for 277 subjects (83.9%) who had three or more CD4 lymphocyte counts recorded during the study period January 1985 through July 1990. Outcome Measures. —Depressive symptoms were assessed using the Center for Epidemiologic Studies—Depression scale (CES-D). All subjects were classified according to two indicators of depression: (1) as overall depressed using a cut point of 16 or higher on the complete CES-D, and (2) as affectively depressed using a cut point of more than 1 SD above the mean on a subscale of the CES-D measuring affective depression. Laboratory and symptom measures, antiretroviral use, demographics, and behavioral measures were also used. The primary outcome measure was the rate of change of the CD4 lymphocyte count. Secondary outcomes were AIDS-free survival and mortality. Results. —At baseline 65 subjects (19.7%) were classified as depressed on the overall scale and 53 (16.1%) were classified as depressed on the affective scale. The unadjusted mean rate of CD4 change was 38% greater for overall depressed subjects than for the overall nondepressed (−0.0812 vs −0.0588×10 9 /L[−81.2vs −58.8/μL per year; P =.07) and 34% greater for affectively depressed subjects than for the affectively nondepressed (−0.0804 vs −0.0598×10 9 /L per year; P =.06). In hierarchical multivariate analysis controlling for antiretroviral use, symptoms, and other predictors, baseline overall depression was associated with an excess decline in CD4 count of −0.0285×10 9 /L per year (95% confidence interval, −0.0496 to −0.0073), and baseline affective depression was associated with an excess decline in CD4 count of −0.0236×10 9 /L per year (95% confidence interval, −0.0464 to −0.0008). Neither overall depression nor affective depression was significantly associated with earlier AIDS diagnosis or earlier mortality. Conclusions. —Overall depression and affective depression predicted a more rapid decline in CD4 lymphocyte counts; this association was not attributable to baseline physiological differences. While the mechanism of the association remains unknown and cannot be addressed directly by this study, the data suggest that it can be explained neither as simply a reflection of perceived somatic symptoms nor as the result of differences in recreational drug and alcohol use. Further study is necessary to determine whether treating depression can alter the course of HIV infection. ( JAMA . 1993;270:2568-2573)

https://jamanetwork.com/journals/jama/articlepdf/409478/jama_270_21_027.pdf

Depressive Symptoms and CD4 Lymphocyte Decline Among HIV-Infected Men

Background: Although depression has been related to chronic disease processes and outcomes, studies examining the relationship between depression and disease progression in persons with human immunodeficiency virus (HIV) infection have produced inconsistent results. Objective: To investigate whether depressive affect is associated with HIV mortality. Methods: This was a prospective cohort study (San Francisco Men's Health Study) using a population-based probability sample of single men living in areas of San Francisco, Calif, with high case rates of acquired immunodeficiency syndrome. Data collection was at 6-month intervals with up to 15 waves of follow-up. Subjects included all 402 homosexual or bisexual men who in July 1984 had serologic evidence of HIV infection and who survived a minimum of 1 wave after baseline. Depressive affect was measured at each wave with the affective subscale of the Center for Epidemiologic Studies— Depression Scale. Laboratory markers, World Health Organization staging, antiretroviral use, and hospitalizations were also used as predictor variables. The primary outcome measure was survival. Results: In a Cox proportional hazards model, a time-dependent measure of depressive affect was associated with greater mortality (adjusted risk ratio, 1.67; 95% confidence interval, 1.01-2.78). Conclusions: Depressive affect was associated with mortality risk, highlighting the importance of diagnosis and treatment of depression among HIV-infected gay and bisexual men. Replication of this effect in incident cohorts with well-characterized dates of HIV infection is needed and, if replicated, an exploration of mediating pathways suggested. Arch Intern Med. 1996;156:2233-2238

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=INTEMED&articleId=622557&pdfFileName=archinte_156_19_012.pdf

Depressive Affect and Survival Among Gay and Bisexual Men Infected With HIV

OBJECTIVES: This study compared history of substance use and episodic use in terms of HIV seroconversion. METHODS: A sample of 337 baseline HIV-negative gay men was followed for 6 years. Bivariate and survival analyses were used to compare 39 converters with nonconverters on substance use behaviors. RESULTS: Seroconverters were consistently more likely to report use of marijuana, nitrite inhalants, amphetamines, and cocaine than nonconverters. Consistent use of nitrite inhalants and amphetamines increases the relative risk of seroconversion, while episodic use does not. Both patterns of cocaine use increase seroconversion risk. CONCLUSIONS: There are three potential mechanisms for an increased risk of conversion due to consistent substance use.

Histories of substance use and risk behavior: precursors to HIV seroconversion in homosexual men.

Objective: To evaluate the efficacy of a cognitive/behavioral skills-building intervention to prevent sexually transmitted diseases (STD) in high-risk heterosexual adults. Design: A randomized controlled trial with assessments at baseline, and at and 5 months. Setting: San Francisco STD Clinic. Patients: A total of 399 patients were randomly assigned to a four-session, individual, multi-component, cognitive/behavioral intervention (n = 199), or a brief standardized counseling session offered to all patients In = 200). Intervention: Based on the AIDS Risk-Reduction Model, the aims of the intervention were to increase prevention knowledge, reduce high-risk psychosocial factors, and build decision-making and communication skills to modify sexual behaviors. Main outcome measures: The primary outcome of interest was STD. The secondary outcome was number of risky sexual activities. Results: There were no differences between the intervention (13%) and control (11%) groups in their acquisition of STD. Among men, condom use increased more at 3 months in the intervention group than the control group (56.8 versus 42.3%; P < 0.05). In addition, the mean number of sexual partners without condom use was lower in the intervention group than in the control group at 5 months (0.6 versus 0.9; P < 0.01). Conclusions: The results suggest that a cognitive/behavioral, skills-building intervention consisting of individual, multiple sessions and follow-up assessments can be implemented and evaluated with high-risk heterosexually active adults attending public STD clinics. Our intervention did not have a significant impact on STD, although it had some impact on behavior in men, but not in women.

Sexually transmitted disease (STD) and HIV risk in heterosexual adults attending a public STD clinic: evaluation of a randomized controlled behavioral risk-reduction intervention trial.

Data from the 1989 Communication Technologies cross-sectional survey of gay men in San Francisco indicate that both levels and correlates of sexual risk are different between younger and older gay men. Gay men under the age of 30 report higher risk behavior for human immunodeficiency virus (HIV) infection than do gay men who are 30 years of age or older. Further, the set of correlates of unprotected anal intercourse are different between younger and older gay men. Both young and old gay men report that having a primary partner and a lower perceived impact of the AIDS epidemic on their sexual behavior are associated with risk. However, among young gay men, reporting a lower attributed risk for HIV infection to unprotected anal intercourse, higher concern about AIDS risks, and shorter length of residence in San Francisco are positively correlated with risk-taking behavior. These associations were not statistically significant among gay men 30 years of age or older. It appears that the circumstances and/or reasons for taking sexual risk are different between older and younger gay men. Prevention programs must be designed so that they are sensitive to the needs of each generation of gay men.

D C Barrett

Papers

Depressive Symptoms and CD4 Lymphocyte Decline Among HIV-Infected Men

Depressive Affect and Survival Among Gay and Bisexual Men Infected With HIV

Histories of substance use and risk behavior: precursors to HIV seroconversion in homosexual men.

Sexually transmitted disease (STD) and HIV risk in heterosexual adults attending a public STD clinic: evaluation of a randomized controlled behavioral risk-reduction intervention trial.

A comparison of younger and older gay men's HIV risk-taking behaviors: the Communication Technologies 1989 Cross-Sectional Survey.