DOH92-DC-1030 ( ) Neuropsychiatric and Psychosocial Study of the HIV-I Infected: A Cross-sectional Nationwide Survey 02-27596158 02-27263141#1254 Email mingbeen@ntumc.org 92 1 1 92 12 31 1
6 11. 2
AIDS,, ; AIDS, HIV-1 (1) HIV-1 AIDS (2) (3) AIDS ( ) BSRS-5 DSM-IV 1604 index assessment 941 59.1% 33.9% 15.9% 7.3% 5.7% 4.9% 2.3% 3
1% dependent variable independent variables OR = 1.005; 95% C.I. = 1.0006-1.0104 OR = 1.8122; 95% C.I. = 1.2207-2.6903 OR = 1.3577; 95% C.I. = 1.0634-1.7335 OR = 2.0161; 95% C.I. = 1.5532-2.6170 4
Research Data Archive, Center for Disease Control, The Executive Yuan, R.O.C. Readme file Project Title: Neuropsychiatric and Psychosocial Study of the HIV-I Infected: A Cross-sectional Nationwide Survey Project Number: DOH91-DC-1061 Executing Institute: National Taiwan University College of Medicine Principal Investigator(P.I.): Ming-Been Lee P.I. Position Title:Professor P.I. Institute: Department of Psychiatry Abstract The society, government and the professionals have paid much attention to the prevention and treatment of AIDS in Taiwan area. However, comprehensive care based on psychosocial, and psychiatric, and ethical aspects for the AIDS patients is still underdeveloped. Besides, the national wide survey of psychological distress and psychiatric morbidity of HIV-infected patients were never performed. The present study is a 2-year longitudinal cohort study that aims to understand the psychosomatic issues and psychiatric diagnosis of HIV infected patients by way of national survey. From this study, the national wide data on psychological, psychiatric and family aspects as well as the ethical issues of HIV-infected patients were disclosed. A series of reliable and valid measures was used to assess the psychological distress, cognitive function, and psychopathology. This study was designed to be a two stages survey study. The screening form of Brief Symptom Rating Scale BSRS-5 was served as screen tool in the first stage. The diagnosis of psychiatric morbidity was made by senior psychiatrists based on Mini International Neuropsychiatric Interview MINI in the second stage. During the two year period, 941 subjects with HIV-1 infection were recruited. Some of the subjects were followed up for 3 to 6 months. The study showed any kind of psychiatric morbidity occurred in 33.9% of our sample and the most frequent diagnosis was adjustment disorder with depressive mood 15.9%.Besides, the most prevalent psychological distress defined by BSRS-5 and reach the moderate severity and above was insomnia followed by depressive mood, anxiety, irritability, interpersonal sensitivity, suicidal ideation, pain, and dyspnea. The psychopathology was positively correlated with functional variables. The neuropsychological test Tail making B was significantly correlated with psychopathology and functional variables. In the logistic regression model, duration of HIV infection, suicidal ideation, dyspnea, pain were significantly correlated with psychiatric diagnosis. In addition to the survey of psychiatric morbidity, via in-depth interview in part of the samples, the main stressors were being diagnosed and the poor prognosis and family conflict. Using focus group discussion and questionnaire survey on the first line case managers revealed that they still need further training on the ethics, law and psychosocial aspects to take care of their registered clients. The present study implied that the psychosocial-ethical care including individual counseling, group/family support and patient-physician communication are rather important to improve the prognosis of the HIV-infected and the quality of health care on the AIDS patients. Key words: HIV-1 infected, Psychiatric morbidity, Risk factors, Prevalence, Medical ethics. 5
1980 George Engel Science biopsychosocial model trigger compliance behavioral modification biofeedback treatment 1980 AIDS ( Lee MB,1985;Lee MB et al,1990 ) 1981 retrovirus HIV HIV 6
HIV HIV 66% 7% 3% 3% HIV 5 20-30% 75% HIV HIV (Morin SF et al, 1984; Perry SW et al, 1984; Levy RM et al, 1985; Perry SW et al, 1986; Rundel JR et al, 1986; Beresford TP et al, 1986; Navia BA et al, 1987; Schmidt U et al, 1988; Butters N et al, 1990; Perry SW, 1990; Cefali FE, 1990; Dilley JW et al, 1992; Snyder S et al, 1992; Catalan J et al, 1992) HIV (Coates TJ et al, 1984;Temoshok L et al, 1989; Rabkin JG et al, 1991; Coates TJ et al, 1989;Ironson G et al, 1990; Capitanio JP et al, 1991; Goodkin K et al, 1992) AIDS 73 75 82 70 600 4D (delirium) (dementia) (depression) (demorale) 4D HIV (AIDS dementia complex ADC) 7
( subacute encephalitis SE) HIV (nonfocal or HIV encephalopathy) 1983 Snider 50 18 SE 1984 Nielsen SE HIV ` Shaw 1985 HIV HIV ADC HIV 40% 10% 70-80% ADC ( ) ( ) ( ) ( ) (microfocal demyelination) HIV (existential plight) 8
(planning for death) ARC 1986 Tross ARC 75% ARC 50% ARC (uncertainty) HIV 1987 HIV 162 ( 148 14 ) 19 DSM -R 38.9 87.3 9
33 (GSI ) 58 HIV 20 10
(1) HIV-1 (2) ( ) (3) (4) HIV-1 AIDS HIV-1 AIDS 11
HIV-1 AIDS HIV-1 AIDS BSRS-5 BSRS-5 Chinese Health Questionare: CHQ 3 4 89% 70% Cheng TA et al, 1986 1585 3 12 CHQ CHQ general medical condition psychiatric morbidity 708 50 Brief Symptom Rating Scale: BSRS 708 50 GSI 0.814 Cronbach Alpha 0.7549 50 BSRS 253 50 GSI 0.898 12
Cronbach Alpha 0.7968 receiver operating characteristic (ROC) analysis psychiatric morbidity 78.9% 74.3% 8 - BSRS-5 Mini International Neuropsychiatric Interview MINI Mini International Neuropsychiatric Interview MINI DSM-IV ICD-10 Axis I David Sheehan Yves Lecrubier DSM-III-R SCID-P ICD-10 CIDI 20 DSM-III-R SCID-P ICD-10 CIDI Sheehan Sheehan Sheehan Function Inventory Trail Making Test sub - cortical dementia 13
Finger Taping Test, Trail Making Test, A B Partington & Leiter, 1949 A B Trail Making Test A 1 25 Trail Making Test B 1 A 2 B 3 - C-.. speed for attention, sequencing, mental flexibility, visual search, motor function SPSS 8.0 Frequencies Cronbach alpha Student s t test α 0.05 5 Fisher s exact test Pearson s product moment Mann-Whitney test α 0.05 Kendall tau logistic regression odds ratio 14
1604 index assessment 941 897 95.3% 44 4.7% Table 1.1 425 236 Table 1.2 34.37±10.88 747 33.31±37.09 Table 3.1 - BSRS-5 10.9% 10.5% 9.6% 7.4 % 6.1% 3.8% 2.9% 0.8% Table 2.1 2.8 Table 3.1 to 3.2 50 BSRS 253 50 GSI 0.898 Cronbach Alpha 0.7968 receiver operating characteristic (ROC) analysis psychiatric morbdity 78.9% 74.3% 8 - BSRS-5 4.33±4.12 66.1% 33.9% 27.8% 22.7% Table 4.1 4.3 - Mini International Neuropsychiatric Interview MINI 15
DSM-IV ICD-10 Axis I 36.2% BSRS-5 BSRS-5 67.2% 81.3% 20% Table 5.1 logistic regression dependent variable independent variables OR = 1.005; 95% C.I. = 1.0006-1.0104 OR = 1.8122; 95% C.I. = 1.2207-2.6903 OR = 1.3577; 95% C.I. = 1.0634-1.7335 OR = 2.0161; 95% C.I. = 1.5532-2.6170 Table 5.2 59.1% 33.9% 15.9% 7.3% 5.7% 4.9% 2.3% 1% Table 5.3 941 425 236 BSRS-5 BSRS-5 r = 0.684 to 0.596; all p < 0.001 Table 6.1 Table 6.2 Table 6.3 16
Trail Making Test Trail Making Test - BSRS-5 sub - cortical dementia Finger Taping Test, Trail Making Test, A B 37 A Trail Making Test A B Trail Making Test B BSRS Trail B r = 0.437; p = 0.007 BSRS-5 r = 0.579; p < 0.001 Trail A r = 0.362; p = 0.028 50 BSRS 34% 26% 34% 12 42 17
18
941 1604 59.1% 33.9% 1% BSRS-5 10.9% HIV HIV sub-clinic HIV Trail B teat HIV HIV AIDS Dementia Complex (ADC) HIV neuron glial cell sub-cortical area psychomotor executive function alogia abulia delirium HIV 19
HIV blood brain barrier HIV HIV DSM-IIIR 38.9 87.3 33 58 Mini International Neuropsychiatric Interview MINI 36.2% 20
existential plight planning for death acquired immunodeficiency syndrome AIDS 1981 1983 human immunodeficiency virus, HIV 21
941 33.9% 16.7% HIV HIV HIV HIV Finger Taping Test, Trail Making Test, HIV 22
stress management 23
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Table 1.1 Basic data: sex Frequency Percent Male 897 95.3 Female 44 4.7 Total 941 100.0 Table 1.2 Basic data: education level Frequency Percent Elementary school 33 3.5 Junior high school 77 8.2 Senior high school 282 30.0 Occupational high school 278 29.5 College 232 24.7 Postgraduate school 39 4.1 Total 941 100.0 Table 1.3 Basic data: year and month of first assessment Frequency Percent 9107 7.7 9108 45 4.8 9109 63 6.7 9110 94 10.0 9111 110 11.7 9112 102 10.8 9201 117 12.4 9202 35 3.7 9203 78 8.3 9204 61 6.5 9205 51 5.4 9206 41 4.4 9207 37 3.9 9208 49 5.2 9209 8.9 9210 9 1.0 9211 26 2.8 9212 8.9 28
Total 941 100.0 29
Table 2: Distribution of symptom Table 2.1 Distribution of symptom: anxiety Frequency Percent Not at all 423 45.0 A little bit 312 33.2 Moderately 149 15.8 Quite a bit 43 4.6 Extremely 13 1.4 Total 941 100.0 Table 2.2 Distribution of symptom: depression Frequency Percent Not at all 375 39.9 A little bit 305 32.4 Moderately 171 18.1 Quite a bit 61 6.5 Extremely 29 3.1 Total 941 100.0 Table 2.3 Distribution of symptom: anger Frequency Percent Not at all 444 47.2 A little bit 266 28.2 Moderately 161 17.1 Quite a bit 55 5.8 Extremely 15 1.6 Total 941 100.0 Table 2.4 Distribution of symptom: inferiority Frequency Percent Not at all 552 58.7 A little bit 237 25.2 Moderately 95 10.1 Quite a bit 45 4.8 Extremely 12 1.3 Total 941 100.0 Table 2.5 Distribution of symptom: insomnia 30
Frequency Percent Not at all 425 45.2 A little bit 245 26.1 Moderately 168 17.8 Quite a bit 71 7.5 Extremely 32 3.4 Total 941 100.0 Table 2.6 Distribution of symptom: dyspnea Frequency Percent Valid Percent Cumulative Percent Not at all 561 59.6 82.7 82.7 A little bit 92 9.8 13.6 96.3 Moderately 19 2.0 2.8 99.1 Quite a bit 5.5.7 99.9 Extremely 1.1.1 100.0 Total 678 72.1 100.0 Missing 263 27.9 941 100.0 Table 2.7 Distribution of symptom: pain Frequency Percent Valid Percent Cumulative Percent Not at all 393 41.8 58.1 58.1 A little bit 199 21.1 29.4 87.4 Moderately 65 6.9 9.6 97.0 Quite a bit 13 1.4 1.9 99.0 Extremely 7.7 1.0 100.0 Total 677 71.9 100.0 Missing 264 28.1 941 100.0 31
Table 2.8 Distribution of suicidal ideation Frequency Percent Valid Percent Cumulative Percent Not at all 682 72.5 73.3 73.3 A little bit 144 15.3 15.5 88.7 Moderately 69 7.3 7.4 96.1 Quite a bit 18 1.9 1.9 98.1 Extremely 18 1.9 1.9 100.0 Total 931 98.9 100.0 Missing 10 1.1 941 100.0 32
Table 3: Descriptive Statistics Table 3.1 Descriptive statistics of other clinical measurements AGE DURA BSRS5_1 BSRS5_2 BSRS5_3 N 940 747 941 425 238 Missing 1 194 0 516 703 Mean 34.3670 33.3092 4.3278 4.0024 3.6586 Std. Deviation 10.8822 37.0892 4.1265 4.0367 4.1522 Skewness 2.412 1.957 1.051 1.095 1.568 Std. Error of Skewness.080.089.080.118.158 Kurtosis 9.105 5.790.899.715 2.163 Std. Error of Kurtosis.159.179.159.236.314 Table 3.2 Descriptive statistics of other clinical measurements Trail A Trail B Social function Family function Work ability N 37 37 321 321 321 Missing 904 904 620 620 620 Mean 28.84 72.68 1.8879 2.0779 2.1963 Std. Deviation 8.75 23.43 2.4723 2.4077 2.5646 Skewness 1.708 1.247 1.379 1.160 1.135 Std. Error of Skewness.388.388.136.136.136 Kurtosis 4.428 1.117 1.107.625.435 Std. Error of Kurtosis.759.759.271.271.271 33
Table 4: Psychiatric Morbidity at Three Waves of Assessments Table 4.1 Proportion of psychiatric diagnosis defined by BSRS-5 total scores 6 at the index assessment Frequency Percent Valid Percent Cumulative Percent <6 622 66.1 66.1 66.1 6 319 33.9 33.9 100.0 Total 941 100.0 100.0 Table 4.2 Proportion of psychiatric diagnosis defined by BSRS-5 total scores 6 at six months after index assessment Frequency Percent Valid Percent Cumulative Percent <6 307 32.6 72.2 72.2 6 118 12.5 27.8 100.0 Total 425 45.2 100.0 Missing 516 54.8 941 100.0 Table 4.3 Proportion of psychiatric diagnosis defined by BSRS-5 total scores 6 at one year after index assessment Frequency Percent Valid Percent Cumulative Percent <6 184 19.6 77.3 77.3 6 54 5.7 22.7 100.0 Total 238 25.3 100.0 Missing 703 74.7 941 100.0 34
Table 5: Diagnosis, Validity, and Predictors Table 5.1 BSRS-5 categories and psychiatric diagnosis cross tabulation Psychiatric Diagnosis Total No Yes Count 360 136 496 BSRS-5 Total < 6 6 % within BSRS-5 72.6% 27.4% 100.0% % within psychiatric Dx 81.3% 44.4% 66.2% Count 83 170 253 % within BSRS-5 32.8% 67.2% 100.0% % within psychiatric Dx 18.7% 55.6% 33.8% Count 443 306 749 % within BSRS-5 59.1% 40.9% 100.0% % within psychiatric Dx 100.0% 100.0% 100.0% Chi-Square = 109.689, p, 0.0001 Table 5.2 Logistic regression model of psychiatric diagnosis defined by BSRS-5 with clinical variables as predictors 95% CI for Exp(B) Variable B S.E. Sig R Exp(B) Lower Upper Age -.0090.0111.4153.0000.9910.9697 1.0128 Duration of illness.0055.0025.0287.0599 1.0055 1.0006 1.0104 Dyspnea.5946.2016.0032.0929 1.8122 1.2207 2.6903 Pain.3058.1247.0142.0720 1.3577 1.0634 1.7335 Suicidal ideation.7012.1331.0000.1822 2.0161 1.5532 2.6170 Dependent variable = psychiatric morbidity defined by BSRS-5 (cutoff point >=6) Nagelkerke - R^2 =.181 Number of selected cases:941 Number rejected because of missing data: 361 Number of cases included in the analysis: 580 35
Table 5.3 Psychiatric diagnoses confirmed by Mini International Neuropsychiatric Interview Diagnosis by MINI N % Dementia due to HIV disease 2.3 Phobia 3.4 Hypochondriasis 4.5 Adjustment disorder with mixed disturbance of emotions and conduct 4.5 Anxiety disorder, NOS 6.8 Major depressive disorder 13 1.7 Dysthymic disorder 17 2.3 Adjustment disorder with anxiety 37 4.9 Adjustment disorder with mixed anxiety and depressed mood 46 6.1 Adjustment disorder unspecified 55 7.3 Adjustment disorder with depressed mood 119 15.9 No formal psychiatric diagnosis 443 59.1 Total 749 100.0 Missing system 192 Total 941 36
Table 6: Correlation Analysis Table 6.1 Correlations between three waves of BSRS-5 total scores BSRS5_1 BSRS5_2 BSRS5_3 Pearson Correlation 1.000.600.596 BSRS5_1 Sig. (2-tailed)..000.000 N 941 425 238 Pearson Correlation.600 1.000.684 BSRS5_2 Sig. (2-tailed).000..000 N 425 425 238 Pearson Correlation.596.684 1.000 BSRS5_3 Sig. (2-tailed).000.000. N 238 238 238 Table 6.2 Correlations between dimensions of Sheehan Functional Scale and BSRS-5 total scores BSRS5_1 Social function Family function Work ability BSRS5_1 Social Family function function Work ability Pearson Correlation 1.000.410.386.369 Sig. (2-tailed)..000.000.000 N 941 321 321 321 Pearson Correlation.410 1.000.723.704 Sig. (2-tailed).000..000.000 N 321 321 321 321 Pearson Correlation.386.723 1.000.692 Sig. (2-tailed).000.000..000 N 321 321 321 321 Pearson Correlation.369.704.692 1.000 Sig. (2-tailed).000.000.000. N 321 321 321 321 37
Table 6.3 Correlations between associated psychical symptom and functions Social Family function function Work ability Dyspnes Pain Pearson Social Correlation 1.000.723.704.197.258 function Sig. (2-tailed)..000.000.004.000 N 321 321 321 215 215 Pearson Family Correlation.723 1.000.692.180.251 function Sig. (2-tailed).000..000.008.000 N 321 321 321 215 215 Pearson.704.692 1.000.132.256 Correlation Work ability Sig. (2-tailed).000.000..053.000 N 321 321 321 215 215 Pearson.197.180.132 1.000.387 Correlation Dyspnea Sig. (2-tailed).004.008.053..000 N 215 215 215 678 677 Pearson.258.251.256.387 1.000 Correlation Pain Sig. (2-tailed).000.000.000.000. N 215 215 215 677 677 38
Table 6.4 Correlations between functions, BSRS-5 total scores and neuropsychological test Social function Family function Work ability Trail A Trail B BSRS5_1 Social function Family function Work ability Trail A Trail B BSRS5_1 Pearson Correlation 1.000.723.704.013.104.410 Sig. (2-tailed)..000.000.938.540.000 N 321 321 321 37 37 321 Pearson Correlation.723 1.000.692.281.437.386 Sig. (2-tailed).000..000.092.007.000 N 321 321 321 37 37 321 Pearson Correlation.704.692 1.000.077.221.369 Sig. (2-tailed).000.000..652.189.000 N 321 321 321 37 37 321 Pearson Correlation.013.281.077 1.000.362.303 Sig. (2-tailed).938.092.652..028.068 N 37 37 37 37 37 37 Pearson Correlation.104.437.221.362 1.000.579 Sig. (2-tailed).540.007.189.028..000 N 37 37 37 37 37 37 Pearson Correlation.410.386.369.303.579 1.000 Sig. (2-tailed).000.000.000.068.000. N 321 321 321 37 37 941 39
: SPMSQ 10 4 4.. 10. 20 3 3 40
(BSRS),, ( ),, 0 1 2 3 4 1. ( ) 0 1 2 3 4 2., 0 1 2 3 4 3. 0 1 2 3 4 4. 0 1 2 3 4 5. 0 1 2 3 4 6., 0 1 2 3 4 7. 0 1 2 3 4 8. 0 1 2 3 4 9. ( ) 0 1 2 3 4 10. 0 1 2 3 4 11. 0 1 2 3 4 12. 0 1 2 3 4 13., 0 1 2 3 4 14. 0 1 2 3 4 15. 0 1 2 3 4 16. 0 1 2 3 4 17. 0 1 2 3 4 18. 0 1 2 3 4 19. 0 1 2 3 4 20. ( ) 0 1 2 3 4 21. 0 1 2 3 4 22., 0 1 2 3 4 23., 0 1 2 3 4 24., 0 1 2 3 4 25. 0 1 2 3 4 26., 0 1 2 3 4 27. 0 1 2 3 4 28. 0 1 2 3 4 29. 0 1 2 3 4 30. 0 1 2 3 4 31. 0 1 2 3 4 32. 41
0 1 2 3 4 33., 0 1 2 3 4 34. 0 1 2 3 4 35. 0 1 2 3 4 36. 0 1 2 3 4 37.,( ) 0 1 2 3 4 38., :, 0 1 2 3 4 39. 0 1 2 3 4 40. 0 1 2 3 4 41. 0 1 2 3 4 42., 0 1 2 3 4 43., 0 1 2 3 4 44. 0 1 2 3 4 45. 0 1 2 3 4 46., 0 1 2 3 4 47., 0 1 2 3 4 48. 0 1 2 3 4 49. 0 1 2 3 4 50. 0 1 2 3 4 51. ( ) 42
(MPI) :,,, ;, ;, 5,, 1. 2. 3. 4., 5.? 6., 7. 8. 9. 10. 11. 12., 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25., 26., 27. 28. 29. 30. 43
( ) 0. 1. 2. 3. 4. 1. ( / ) 2. ( ) 3. ( ) 4. ( ) 5. ( ) 6. ( ) 7. ( ) 8. ( ) 9. ( ) 10. ( X Y) 11. ( ) 12. ( ) 13. ( ) 14. ( ) 15. ( ) 16. ( ) 1. 2. 3. 4. 44
------------------------------------------------------------- 1. 2. 3. 4. ( ) 5. 45