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Study finds depression higher among inpatients
Motor functioning problems also may play role
When New Orleans investigators analyzed data about HIV patients who were hospitalized and those who weren’t, what they found was surprising: Only a few significant differences existed between these groups, and one of the most prominent was that depression was more common among the hospitalized group.
The other differences were those in the group that used hospital resources were less likely to be able to name one of the medications, more likely to test positive for opiates, and more likely to say they had difficulty walking or moving than previously.1
"We have a very nicely furnished inpatient AIDS ward that we’re proud of, but we’re not proud of how full it is all the time," says Ruth E. Berggren, MD, an assistant professor of medicine for infectious diseases at Tulane University Medical Center in New Orleans.
Berggren, who co-authored the study, says that while New York and California have had large decreases in the numbers of HIV-related hospital admissions, the New Orleans HIV clinic’s hospitalization rate has remained high.
Things are getting better
"I think we can infer that things are not getting better in New Orleans, the way things seem to be getting better in New York and California," she says.
"Here in New Orleans we have a state-of-the-art AIDS clinic, which takes care of about 3,000 people and is funded by Ryan White," Berggren explains. "It’s well-staffed by expert physicians. It has all the social services that you could want, and we have a multidisciplinary clinic, and so our patients have access to care and an entire supplemental package of services with free medications if they need them."
And yet hospitalization rates remain dismaying, she says. "We’re part of a trend that’s being seen in the Southeast. So what’s the problem?"
The case control study analyzed the similarities and differences between patients admitted to the AIDS ward and patients who had low CD4 cell counts, but were seen only in outpatient settings during the previous 12 months, she says.
The study group and control group were given a urine toxicology screening for street drugs, a Beck Depression Inventory, a Substance Abuse Subtle Screening Inventory (SASSI), and an Alcohol Use Disorders Identification Test (AUDIT). The CD4 cell counts, viral load, and hepatitis status were reviewed for each group, and each participant was asked questions about medication, mobility, incarceration, employment, and other items, Berggren notes.
Whether the subjects were inpatients or outpatients, there was a 25% prevalence of urinary cocaine, she says. "We found that 18% tested positive for marijuana; 32% were positive on the AUDIT for problem alcohol ingestion, and 72% have a history of incarceration."
The patients in both groups also had very low incomes with a median income of $6,700, and 43% had less than a high school education, adds Berggren. "The thing is that all of these are risk factors for hospital admission," she explains. "So we’re looking within a very high-risk population to see who are the folks at the very highest risk of getting themselves in a hospital."
The idea is that if researchers can prospectively identify these very high-risk individuals then the HIV clinic can target people who fit that profile for special interventions, Berggren says.
With all of the similarities between the hospitalized group and the control group, the few differences were striking, she adds.
For one thing, more than 20% of the group with hospital admissions tested positive on the Beck Depression Inventory, while fewer than 5% of the outpatients tested positive, Berggren says. "These are associations, and we cannot infer causality, because by virtue of getting hospitalized, someone’s depression score may go up, and we recognize that."
"There also was a highly striking difference in response to the question about motor impairment," she notes. HIV patients were asked, "In the last year, have you lost the ability to walk or move around like you did before?" Among the hospitalized group, 35% said, "Yes," while only 8% of the outpatient group said, "Yes," Berggren says.
When asked whether they could name any of their medications, more than 40% of the hospital admission group said, "No," while more than 80% of the outpatient group said they could name at least some of their medicines, she says.
And while both groups had high levels of cocaine and marijuana in the toxicology screening, about 32% of the patients who had been hospitalized also tested positive for opiates, compared with 5% of the outpatient controls. Also, about 10% of the hospital admission group tested positive for benzodiazepines, compared with 1% to 2% of the controls, Berggren adds. "In a high substance-using population, there are certain substances that are more likely to lead you to a bad end."
The benzodiazepines, which include Valium and Xanax, might be prescribed by mental health care providers, which might fit in with the finding that investigators found more depression among the hospital admission group, she notes.
Finally, the inpatients were significantly less likely to take antiretroviral medication and opportunistic infection prophylaxis, she adds.
Another difference was that outpatients were much more likely than inpatients to be the primary caretaker of children, Berggren says.
"We thought it’d be the other way around," she explains. "We thought these would be the women who were not taking care of themselves and doing badly."
About 60% of the outpatients were primary caretakers of children, Berggren points out.
Rather, it appears that the women who are doing well enough to take care of their children also are taking better care of themselves, she says.
"The viral load was higher in the hospital admission group than in the outpatients, but the outpatients had a pretty high viral load, as well," Berggren says. "There was high unemployment in both groups with 80% unemployment in the hospital admission group and 60% in the controls."
The inpatients were less likely to adhere to their antiretroviral therapy regimen and opportunistic infection prophylaxis.
Investigators also screened subjects with the Rapid Evaluation of Adult Literacy in Medicine (REALM) test, and found low literacy in both groups, Berggren says.
"The average subject had a literacy level that would place them around seventh grade, and that’s a level where medical literature suggests they might struggle with most currently available patient education materials," she says.
As a result of the research, Berggren has created a screening tool that targets these very high-risk HIV patients in hopes of reducing hospitalization rates and health care costs.
HIV clinicians may be able to identify people at the greatest risk of hospitalization by asking patients to name their medications and providing remedial education to those who are unable to name even one drug, and they could ask that the patient recruit a family member or friend to be an adherence monitor, she suggests.
Assessing substance use and depression is another strategy for identifying this population.
"There’s a fair amount of undiagnosed and untreated depression, and if that’s addressed, you could potentially make an impact in their hospitalization rates," Berggren adds.
"Opiate addiction should be addressed more proactively, and methadone clinics need to be easier to use and more accessible," she notes.
1. Tompkins JC, Berggren RE. A root-cause analysis of HIV/AIDS-related hospital admissions: A case-control pilot study. Presented at the IDSA conference. Boston; September/ October 2004. Poster: 843.