Erbelding, Emily J. MD, MPH*†; Hummel, Banu MSW*†; Hogan, Terry MPH,† and; Zenilman, Jonathan MD*
From the *Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, and the †Division of Communicable Diseases and Epidemiology, Baltimore City Health Department, Baltimore, Maryland
Reprint requests: Emily J. Erbelding, MD, MPH, 1830 E. Monument St., Room 448, Baltimore, MD, 21287. E-mail: firstname.lastname@example.org
Received for publication June 23, 2000, revised September 15, 2000, and accepted October 5, 2000.
Background: Depressed mood syndromes may limit the ability of patients with sexually transmitted diseases (STDs) to process risk reduction messages and change behavior. We undertook screening for depression in an urban STD clinic.
Goal: To define the prevalence of depressed mood among STD patients in Baltimore, Maryland.
Study Design: A convenience sample of 125 patients presenting to an STD clinic completed the 30-item General Health Questionnaire (GHQ). Endorsement of ≥ 6 depressive symptom items on the GHQ was considered probable depression.
Results: Of 125 patients screened, 39.2% had GHQ scores above the threshold. Women were more likely to have probable depression than men (51.9% versus 31.9%, P = 0.023). There was no association of substance use and depressed mood, nor of a diagnosed STD and depressed mood.
Conclusions: Depressive symptom rates are extremely high among STD patients, which may compromise the success of risk reduction counseling.
PATIENTS PRESENTING FOR CARE of sexually transmitted diseases (STD) in areas with a high prevalence of HIV are at very high risk for HIV infection and are a major focus of HIV prevention services. Behavioral intervention trials, such as NIMH Multisite HIV Prevention Trial and the CDC Project RESPECT, demonstrated significant reductions in the numbers of unprotected sexual encounters and reductions in incident STDs through behavioral interventions. 1,2 These interventions were designed to develop not only cognitive awareness of HIV prevention methods, but also the behavioral skills that enable personal risk assessment and safer sex negotiation. But the effectiveness of behavioral interventions may be more limited when the target population has fundamental impairments limiting motivation, sense of self-worth, self-efficacy, and hope for the future. Thus, those suffering from depression may not derive benefit from behavioral interventions that might prove to be very successful in other segments of the population.
High rates of depressive symptoms and of primary mood disorders are described in those already diagnosed with HIV infection, 3,4 though it remains unclear whether depressive symptoms and mood disorders precede acquiring HIV infection or whether they manifest clinically following an HIV diagnosis. Data reflecting the epidemiology of mental health disorders among those at high risk for STDs are limited. In the pre-AIDS era, high rates of depressive symptoms and “psychiatric disturbance” were described in British veneral disease clinic attendees. 5,6 In the United States, high rates of past STDs were identified from public registry data among a consecutive series of psychiatrically distressed patients seeking mental health services in an emergency department. 7 Though depressed libido and anhedonia are standard clinical criteria for the diagnosis of clinical depression, sexual risk taking has also been associated with high depressive symptom scores in several behavioral surveys. 8–11 Because depressive mood syndromes may impact negatively on motivation for behavior change, a high prevalence of depression among those targeted for STD/HIV prevention services may compromise the success of any type of risk reduction counseling. It is not routine to systematically assess for depressive mood syndromes or other indicators of mental distress in those seeking STD care, in spite of the limits these symptoms may impose on behavior change.
Using a standard instrument developed to screen for depression in general medical practice, we sought to estimate the prevalence of depressive symptoms in patients seeking services in an inner city STD clinic in Baltimore, Maryland.
The study was approved by the institutional review boards of both the Baltimore City Health Department and of Johns Hopkins Medical Institutions. Patients presenting for care at the Baltimore City Health Department Druid STD clinic were eligible for participation. Days designated for screening occurred between August 1998, and February 2000, depending upon the availability of research staff. A convenience sample of 133 patients were approached in the clinic waiting areas and agreed to complete the General Health Questionnaire (GHQ), which is a 30-item inventory querying on thoughts and feelings indicative of psychological distress that has been well-validated as a screening tool for depression in medical practice.12
Patients were all offered a clinical evaluation for STDs according to standard clinical procedures. Exams included specimen collection for Neisseria gonorrhoeae culture in men (urethra) and women (endocervix). Diagnostic testing for Chlamydia trachomatis (Roche Amplicor, Indianapolis, IN) was performed on endocervical secretions from all women undergoing a clinical evaluation. Urethritis was diagnosed in men by the presence of ≥ 4 white blood cells (WBCs) on Gram stain of urethral secretions. Trichomonal vaginitis, candidal vaginitis, and bacterial vaginosis were diagnosed by wet mount examination of vaginal secretions, and syphilis was diagnosed using standard clinical criteria, darkfield lesion examination, and serologic testing. All patients received risk reduction counseling and were offered voluntary HIV serologic testing. Patient demographics, reason for visit, risk behaviors including substance use in the past week, and STD clinical diagnosis were abstracted from the medical record.
Symptom scores of ≥ 6 on the GHQ were considered “probable depression,” as scores above this threshold have the greatest utility in discriminating between cases and noncases in medical practice. 12,13 Statistical analysis was performed using Epi Info 6.03 (CDC, Atlanta, GA). Chi-square analysis was used to compare differences in categorical data between groups. Means of continuous variables were compared using Student t test.
Demographic variables, reason for visit, and clinical STD diagnosis for participating male and female patients are presented in Table 1. Of 133 patients completing GHQ screening, 125 could be matched to a medical record documenting services received that day. Of these 125 participants, 39.2% had a depressive symptom score above the clinical cut-off for probable depression. Women were more likely to be classified with probable depression than were men (odds ratio [OR] 2.38; 95% CI 1.04, 5.26;P = 0.023) and had higher mean GHQ scores (9.37 ± 7.95) than did men (4.66 ± 4.22, P < 0.001). However, men were more likely than women to report getting high on substances (heroin, cocaine, or alcohol to intoxication as a combined variable) in the past week (OR 5.16; 95% CI 1.90, 14.56;P < 0.001). There was no association between probable depression and self-reported use of substances in the past week (OR 0.68; 95% CI 0.39, 1.56, P = 0.31). Furthermore, there was no association between the stated reason for visit and the outcome of probable depression by GHQ screening (OR for STD symptoms 0.70, 95% CI 0.30, 1.63, P = 0.36; OR for STD contact 0.66, 95% CI 0.16, 2.58, P = 0.51). There was also no association between having an STD diagnosed at the clinical encounter and the outcome of probable depression (OR 0.53, 95% CI 0.23, 1.21, P = 0.10).
Other than effective STD treatment, current HIV prevention interventions emphasize client-centered counseling to promote behavior change. 1,2 Behavioral interventions recruiting from STD clinics (including our Baltimore sites) have proven successful in promoting behavioral change. However, the incremental effect is modest, and the studies are biased towards those motivated to complete the intervention and evaluation protocols. We believe that a high prevalence of depressive mood syndromes among the population seeking STD services may significantly limit the success of standard behavior change counseling in actual practice.TABLE
In our population, we demonstrated high rates of depressive symptoms, particularly in women. Of patients screened, 39.2% scored above a clinical threshold that would warrant a referral for mental health services among patients seen in general medical practice. Scores above the cut-off (GHQ score ≥ 6) had a specificity of 90% in detecting those with a clinical determination of current major depression upon psychiatric referral in the HIV clinic of Johns Hopkins Hospital. 4 This high prevalence of probable depression in our sample suggests that the prevalence of depressive mood syndromes in the STD clinic population may be at least as high as the prevalence (20%) described in hospitalized medical inpatients. 14 These data also suggest that depressive mood syndromes may exist at much higher rates in persons seeking STD care than in the general population, where the one-month prevalence of major depression has been estimated at 1.8% for the US as a whole and 2.2% for Baltimore. 15
STD clinic attendees may suffer from depressed mood for a number of reasons. The prevalence of substance use is often very high in STD patients, 16,17 suggesting that substance-induced mood states or substance withdrawal may contribute significantly to the depressed moods reported by these patients. However, in our sample there was no association between substance use in the past week by self-report and probable depression by GHQ screening. The life circumstances surrounding an individual’s presentation for STD services, such as a disrupted relationship, may lead to the endorsement of items indicating mental distress on a screening questionnaire. We did not collect data on significant negative life events or other life stressors in this study. We were only able to use data that had been collected as a routine part of clinical STD practice to evaluate parameters that might be indirectly linked to stressors, such as a disrupted relationship. In this sample, there was no relationship between reason for STD clinic visit (such as “known or suspected STD contact”) and probable depression by GHQ score, nor was there an association between an STD clinical diagnosis and probable depression.
This study is limited by the fact that the study sample was not drawn randomly from the clinic population, but was drawn from patients present in the waiting room at times during which members of the research staff were free to commit to study screening. Therefore, the collected data might not have been representative of those seeking STD clinical services in the clinics as a whole. In fact, patients with the diagnosis of gonorrhea were over-represented in this sample (56% of all study participants, compared to 12% of diagnoses in those presenting for clinical services during the sampling timeframe;P < 0.001), raising the possibility of sampling bias. However, there was no association between the clinical diagnosis of gonorrhea and of probable depression by screening. This would argue against any over-sampling of specific disease cases leading to a study sample biased toward a greater degree of mental distress. The study is also limited by the lack of a true “control” patient population. Therefore, we cannot conclude that STD attendees suffer more mental distress than other inner-city residents seeking publicly funded services. However, given the high risk for HIV/STD acquisition in this patient population and the emphasis on behavior change to prevent HIV/STD, a high prevalence of depressive mood syndromes may have unique significance in STD clinic patients.
In summary, our data suggest a high prevalence of depressive mood syndromes in STD patients, particularly women. While indicators of substance abuse were also very high in this group, high depressive symptom scores occurred independently. Rates of depressive mood syndromes occurring to the degree we describe here may substantially reduce the effectiveness of traditional risk reduction counseling in clinical STD practice. Like STD cofactors, depressive mood syndromes may represent treatable conditions that increase an individual’s susceptibility to HIV. A more thorough understanding of the epidemiology of mood disorders and their relationship to high-risk sexual behavior in the population at risk for STDs is urgently needed.
1. National Institute of Mental Health Multisite HIV Prevention Trial Group. The NIMH multisite HIV prevention trial: reducing HIV sexual risk behavior. Science 1998; 280: 1889–1894.
2. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk reduction counseling to prevent human immunodeficiency virus and sexually transmitted disease: a randomized clinical trial. Project RESPECT Study Group. JAMA 1998; 280: 1161–1167.
3. Lyketsos CG, Federman EB. Psychiatric disorders and HIV infection: impact on one another. Epidemiol Rev 1995; 17: 152–164.
4. Lyketsos CG, Hutton H, Fishman M, et al. Psychiatric morbidity on entry to an HIV primary care clinic. AIDS 1996; 10: 1033–1039.
5. Pedder JR, Goldberg DP. A survey by questionnaire of psychiatric disturbance in patients attending a venereal diseases clinic. Brit J Ven Dis 1970; 46: 58–61.
6. Fitzpatrick R, Frost D, Ikkos G. Survey of psychological disturbance in patients attending a sexually transmitted diseases clinic. Genitourin Med 1986; 62: 111–115.
7. Sitzman BT, Burch EA Jr, Bartlett LS, et al. Rates of sexually transmitted diseases among patients in a psychiatric emergency service. Psychiatr Serv 1995; 46: 136–140.
8. Kelly JA, Murphy DA, Bahr GR, et al. Factors associated with severity of depression and high-risk sexual behavior among persons diagnosed with HIV infection. Health Psych 1993; 12: 215–219.
9. Strathdee SA, Hogg RS, Martindales L, et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men. J Acquir Immune Def Syndr Hum Retrovirol 1998; 19: 61–66.
10. DuRant RH, Getts A, Cadenhead C, et al. Exposure to violence and victimization and depression, hopelessness and purpose in life among adolescents living in and around public housing. J Develop Behav Ped 1995; 16: 233–237.
11. Alegria M, Vera M, Freeman DH Jr, et al. HIV infection, risk behaviors, and depressive symptoms among Puerto Rican sex workers. Am J Pub Health 1994; 84: 2000–2002.
12. Goldberg D. Manual of the General Health Questionnaire. Windsor: NFER Publishing Company, 1979.
13. Goldberg D. Identifying psychiatric illness among general medical patients. BMJ 1985; 291: 161–162.
14. Schwab JJ, Bialow M, Brown JM, et al. Diagnosing depression in medical inpatients. Ann Intern Med 1967; 67: 695–707.
15. Regier DA, Boyd JH, Burke JH, et al. One-month prevalence of mental disorders in the United States. Arch Genl Psych 1988; 45: 977–986.
16. Hutchinson CM, Rompalo AM, Reichert CA, et al. Characteristics of patients with syphilis attending Baltimore STD clinics. Arch Int Med 1991; 151: 511–516.
17. Zenilman JM, Hook EW III, Shepherd M, et al. Alcohol and other substance use in STD clinic patients: Relationships with STDs and prevalent HIV infection. Sex Transm Dis 1994; 21: 220–225.