Abstract
The objective of this study was to identify key mood, social, and functional correlates of current participation in mental health treatment, and identify barriers to participation in mental health treatment, among older HIV+ Veterans. One hundred fifty HIV+ Veterans, aged 50 years and older, anonymously completed a survey assessing current self-reported mood, social support, daily functioning problems, mental health service utilization, and barriers to participating in mental health services. Veterans also completed the 2-item Patient-Health Questionnaire (PHQ-2), a validated depression-screening instrument frequently used in primary care settings. Overall, forty-four percent of participants screened positive on the PHQ-2. Fifty-five percent of those who screened positive on the PHQ-2 were participating in mental health treatment. Of those 45% Veterans who screened positive on the PHQ-2 and were not in treatment, two-thirds (66%) stated they had been offered services; however, they were not engaging in or accepting the services they were offered. Regardless of PHQ-2 status, current self-reported depressive symptoms emerged as an independent, significant positive predictor of participation in mental health treatment, whereas anxiety, HIV-related stigma, sufficiency of social support, and daily functioning problems were not associated with mental health treatment utilization. Primary reported barriers to mental health treatment included scheduling/availability, travel time and transportation, and discomfort with group settings. Results of this study suggest there may be a need to better engage older HIV+ Veterans in depression-related treatment. The use of telehealth technology, such as teletherapy, electronic devices and cell phone-based programs, may be beneficial in helping to overcome many barriers reported by older HIV+ Veterans that restrict their participation in mental health treatment.
Keywords: HIV/AIDS, Depression, social support, mental health, Veterans Administration
Introduction
The Veterans Health Administration (VHA) is the largest single provider of HIV care in the United States, providing care for approximately 24,000 HIV-infected (HIV+) Veterans annually. One out of every 250 Veterans receiving services at the VHA are living with HIV/AIDS 1. Due to advances in highly active antiretroviral therapy and higher late life infection rates, a substantial portion of these HIV+ Veterans are 50 years of age or older, and this number continues to rise 2,3. While Veterans of all ages face additional challenges beyond their HIV+ status, older Veterans with HIV face numerous behavioral health problems 4–7.
There is a pressing need for increased knowledge about the behavioral health needs of older HIV+ Veterans. Prevalence rates of mood and substance disorders are elevated in older HIV+ persons compared to older HIV- adults, and have been reported to be as high as 50% in HIV+ persons 8. In addition to heightened risk for clinical depression, those aging with HIV are at increased risk for negative mood and apathy compared to those without HIV infection 9. Moreover, the expected declines in diagnoses of major depression associated with older HIV- persons are not generally apparent in HIV+ persons 10–13. This co-occurrence of mental illness and HIV results in poorer health outcomes, including decreased CD4 T-lymphocytes, increased viral loads, and higher healthcare costs 14. In terms of psychosocial functioning, the Veterans Aging Cohort Study found that social isolation is related to greater risk of hospitalization and death in HIV+ Veterans compared HIV- Veterans 15. Moreover, this population faces additional burden from HIV-related stigma and disability, which is frequently compounded by ageism, and psychosocial challenges such as availability of social support. Despite the considerable risks associated with this population, studies estimate 40–90% of mental health (MH) concerns remain undetected in primary care settings 16. This lack of adequate detection results in MH problems going untreated among older HIV+ adults. If these problems could be more readily identified, more patients would potentially be offered treatment. Whether they engage in treatment is another important question, and this study aims to discover predictors of engagement and potential barriers to mental health service utilization.
This study’s first aim was to identify key mood, social, and daily functioning correlates of current participation in MH participation in an older HIV+ Veteran sample. The Patient Health Questionnaire-2 PHQ-2; 17 was utilized to identify patients in need of MH services. The PHQ-2 is commonly used as a depression screener in Primary Care and Infectious Disease clinics, and positive screens often prompt MH service referrals. Next, predictors of treatment utilization were explored among participants with positive PHQ-2 screens. Predictors of treatment engagement were also evaluated based on endorsement of current self-reported depressive symptoms. The second aim was to examine barriers to participating in MH treatment. Treatment barriers have not been formally evaluated, despite the substantial portion of Veterans living with HIV and comorbid diagnoses not accessing VA services. Potential obstacles likely include identifying patients with the greatest need for treatment, scheduling difficulties, time and travel to treatment, and privacy concerns. The examination of factors relating to barriers and engagement in MH treatment may lead to targeted solutions for this growing and vulnerable population.
Material and Methods
Participants and Design.
Participants included 150 older (age range=50 to 81 years) HIV+ Veterans receiving HIV-related medical care at the VA San Diego Healthcare System. Data were collected from February 2014 to May 2014. Potential HIV+ participants were identified and approached by clinical staff at the VA Special Infectious Diseases Clinic (SPID) during their routine medical visit and asked to complete an anonymous survey. Surveys were completed in the waiting area and sealed in an envelope by the participant. Two hundred and sixty-five Veterans completed our survey, although only Veterans aged 50 and older were included in the analysis. Nine percent of patients approached refused to complete the survey, ten percent did not return it, and six percent began the survey and discontinued. The study was approved by the VA San Diego Healthcare System Institutional Review Board. All participants received a copy of a stamped informed consent and the California Experimental Subject’s Bill of Rights.
Measures.
Demographic Characteristics.
To ensure anonymity, age was the only demographic characteristic collected. There are a very small number of HIV+ women who receive care at the SPID clinic, so we did not collect sex as a demographic as it would have been considered identifying information.
Mental Health Needs Assessment Survey.
We developed a self-report Mental Health Needs Assessment survey to evaluate mental health, psychosocial, and daily functioning problems of HIV+ Veterans, as well as MH utilization. Survey questions were developed through a literature review and vetted through a consensus process with experts in the field and with VA SPID clinical staff. Depressive symptomatology was measured by the Patient Health Questionnaire-2 PHQ-2; 17 and a yes/no item (“Are you currently suffering from depression”). The PHQ-2 and yes/no depression item were highly correlated (r=0.69, p<0.001). Dichotomous (yes/no) items were used to assess anxiety, stress, HIV-related stigma, and daily functioning problems in the following areas: activities of daily living (ADLs), instrumental activities of daily living (IADLs), antiretroviral adherence, and driving problems. A dichotomous variable was created by collapsing endorsement on one of more of the daily functioning problems into “yes” and no endorsement of any problems into “no”. The survey also included the following yes/no questions: 1) “Do you feel you have sufficient support to address your mental health needs at this time?”; 2) “Do you feel the San Diego VA is adequately addressing your mental health needs as a person living with HIV/AIDS?”; 3) “Have you been offered mental health treatment at the San Diego VA?” We wanted to assess mental health needs and did not want to burden the participants or staff with long measures, which is why we chose to use these brief, dichotomous questions instead of validated instruments of anxiety, stress, stigma, and daily functioning. Additionally, the participants completed our survey in the waiting area prior to their clinic appointment, so we needed to ensure the survey could be completed in a short time so it would not to disrupt the flow of the clinic.
Additionally, participants were asked an open-ended question regarding barriers to participating in MH treatment:”What do you feel would keep you from attending group sessions designed specifically to support mental health needs for Veterans with HIV?” Group therapy was selected as a prompt due to services the authors would be interested in implementing. Two authors (RCM and ES) independently categorized responses to the open-ended question into 5 categories: travel time and transportation costs to the VA (e.g., “distance and time to VA”), group settings (e.g., “I do not do well in group settings;” “I don’t want to be outed”), time constraints (e.g., “my busy schedule;” “time off from work”), not needed (e.g., “not necessary at this time”), and other (e.g., “HIV stigma;” “health-related problems”). Interrater reliability of coding of the open-ended responses was excellent, with Kappa = 0.90 (p<0.001). Discrepancies were discussed by the two authors and resolved.
Statistical Analyses.
IBM SPSS Statistics version 21 was used to conduct all analyses 18. A PHQ-2 cut point of > 2 was used based on improved sensitivity over more conservative cut points 19. Participants with a positive PHQ-2 screening were compared based on whether they were or were not participating in MH treatment. Chi-square tests were conducted to examine differences in rate of mood (i.e., depression, anxiety, and stress), social support, and functional problems between the two groups. Logistic regression was used to identify independent correlates of participation in MH treatment.
Results
Mood, Social and Functional Correlates of Mental Health Service Utilization.
Six participants did not complete the PHQ-2 questions, which left 144 participants for analyses. Forty-four percent of the participants screened positive for depressive symptomatology (PHQ-2 = > 2). Of those screening positive, 55% reported participation in MH treatment. A majority of these services were obtained at the VA (89%). Our survey did not specify if community services were obtained through the VA’s Choice Act 20 or independently. Sixty-six percent of Veterans who screened positive on the PHQ-2 and were not in MH treatment stated they had been offered services; however, they were not engaging in or accepting the services they were offered. Among those with positive PHQ-2 screens, participants who reported they were suffering from HIV-related stigma was more likely to be in treatment (Chi-Square = 4.22, p=0.04) whereas current self-reported depressed mood, anxiety, stress, functional problems, or insufficient social support were unrelated to treatment utilization.
Next, we evaluated predictors of MH utilization regardless of PHQ-2 status to further understand treatment engagement. Overall, approximately one-third (n=47) of the sample was participating in MH treatment. Of these participants, 77% received MH care at the VA and 23% in the community. Table 1 shows age, and mood, social and functional characteristics by group (participating in MH treatment: yes/no). Results from univariable analyses indicated HIV+ Veterans in MH treatment were significantly more likely to report current depression (Chi2 = 30.75, p<0.001), anxiety (Chi2 = 27.30, p<0.001), stress (Chi2 = 15.90, p<0.001), HIV-related stigma (Chi2 = 6.24, p=0.01), and functional problems (Chi2 = 13.02, p<0.001), and less likely to report having social support to address their mental health needs (Chi2 = 7.13, p<0.01; Table 1). These factors were entered into a logistic regression model. Results indicated current depressive symptom reporting (OR=5.98, OR 95% CI=1.16–30.72, p=0.03) was the only independent significant predictor of current MH treatment participation.
Table 1.
Sample Characteristics and Descriptives
| Participating in Mental Health Treatment N=47 |
Not Participating in Mental Health Treatment N=103 |
||
|---|---|---|---|
| Variable | M(SD) or % | M(SD) or % | p-value |
| Age (M(SD)) | 59 (6) | 60 (8) | 0.29 |
| History of Psychiatric Diagnosis | |||
| History of Depression Diagnosis (% yes) |
87% | 44% | <0.001 |
| History of Anxiety Diagnosis (% yes) |
67% | 32% | <0.001 |
| Current Mood | |||
| PHQ-2 (M(SD)) | 3.0 (2.1) | 1.1 (1.7) | <0.001 |
| Current Depression (% yes) | 75% | 25% | <0.001 |
| Current Anxiety (% yes) | 72% | 25% | <0.001 |
| Current Stress (% yes) | 38% | 29% | <0.001 |
| Social Variables | |||
| Sufficient support to address mental health needs at this time (%yes) |
66% | 85% | <0.01 |
| HIV-Related Stigma (% yes) | 41% | 20% | 0.01 |
| Daily Functioning Problemsa (% yes) |
67% | 31% | <0.001 |
Includes problems with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), medication adherence, and/or problems driving. PHQ-2 = Patient Health Questionnaire-2.
Mental Health Service Utilization at the VA San Diego
As shown in Table 2, participants in MH treatment (either VA or community) were less likely to feel the VA was adequately addressing their MH needs (Chi2=8.14, p<0.01), although a majority of those in treatment still felt the VA was adequately addressing their needs (71% vs. 90%). Participants in treatment were also significantly more likely to have been offered MH treatment at the VA San Diego. Current mood problems (depressed mood, anxiety, and stress) were reported by approximately one-quarter of Veterans not currently participating in MH treatment. Of those Veterans reporting current MH problems and not in treatment, 78% stated they had been offered services, while 22% had not.
Table 2.
Perceived Differences in Adequacy of Mental Health Service Offerings among Veterans Participating or Not Participating in Mental Health Treatment.
| Participating in Mental Health Treatment N=47 |
Not Participating in Mental Health Treatment N=103 |
||
|---|---|---|---|
| M(SD) or % | M(SD) or % | p-value | |
| Feel San Diego VA is adequately addressing mental health needs as a person living with HIV/AIDS (% yes) |
71% | 90% | <0.01 |
| Been offered mental health treatment at the San Diego VA (% yes) |
87% | 52% | <0.001 |
Barriers to Older HIV-Infected Veterans Participating in Mental Health Treatment.
Seventy-one participants responded to an open-ended question regarding barriers to participating in VA MH treatment (i.e., group therapy). Five participants reported more than one treatment barrier. The following descriptive categories emerged: 1) scheduling/availability (28%); 2) travel time and transportation to and from the VA (27%); 3) dislike of group settings (23%); and 4) not needed (10%). Additional patient-reported barriers included HIV-associated stigma, shame, disinterest, and health-related problems (<18% frequency).
Discussion
Depression and other MH problems, such as anxiety, stress, and HIV-related stigma, are common among older HIV+ Veterans, yet the unique needs of this group warrant additional investigation given that a majority of HIV+ Veterans are aged 50 years of age and older 3. In the present study we found that all of the aforementioned factors, along with social support and functional problems, were significant correlates of participation in MH treatment among older HIV+ Veterans. One explanation for these findings is that Veterans receiving treatment are in greater need of services, and it is precisely because of these increased MH needs that they are receiving services. We also found current MH problems (depressed mood, anxiety, and stress) in approximately one-quarter of Veterans currently not participating in MH treatment. A majority of these Veterans had been offered services (78%), but for unknown reasons chose not to engage. An additional one-fifth of those identified as potentially in need of services denied they had been offered such services. It may be that these participants did not recognize the offered MH services as such an offer. It may also be that the many medical and psychosocial co-morbidities faced by this relatively “new” Veteran population necessitate a coordinated care, team-based approach, similar to chronic care models that exist for other chronic illnesses (e.g., diabetes). These findings are consistent with prior work by Zaniani et al. (2007), who found that despite evidence of need, older HIV+ adults were less likely to receive care for MH and substance abuse than their younger counterparts. As a whole, the VA has made tremendous strides in increasing MH treatment access in recent years, as evidenced by a 500,000 increase in Veterans receiving specialized MH treatment at the VA from 2006 to 2013 21. As seen in Figure 1, the number of VA San Diego SPID clinic patients has steadily increased, and the rates of Veterans co-enrolled in the SPID and MH clinics has increased at a comparable rate. Additionally, the VA has played a leading role in recognition of potential improvements in both access efficiency, and treatment efficacy, through provision of MH care within primary care clinics, rather than specialized MH clinics 22,23. The successful integration of many MH services into primary care clinics significantly improved both access, and quality of mental health care provided (Watts, Shiner, Pomerantz, Stender, & Weeks, 2007). Our findings suggest that many HIV+ Veterans do not feel the MH clinic is meeting their needs, and further expansion of the existing integrated model to include specialized MH services for these Veterans within primary care clinics may be warranted.
Figure 1.
Prevalence rates of unique HIV-infected Veterans seen at the VA San Diego SPID clinic and both the SPID and Mental Health clinic from 2009–2013.
It is important to note that the most commonly reported barriers to MH treatment were issues such as scheduling/availability, travel time and transportation costs. The use of telehealth technology to address MH needs, such as teletherapy, electronic devices and cell phone-based programs, can help overcome many of these common barriers to treatment. In order to increase access to care, VA has implemented telemental health in many clinics 21. Leveraging this technology in infectious disease clinics would help increase the flexibility of appointment times to sync with the schedules of older HIV+ Veterans, reduce travel time and distance, and ultimately may improve quality of life in these Veterans. Another notable barrier to treatment was dislike of group settings. While our survey specifically asked about interest and barriers to group therapy, thereby priming participants to think about group treatment, it nonetheless is an important barrier within this population, especially considering the high reported rates of HIV-related stigma. Telehealth technology may address this barrier, and there are several emerging MH cell phone-based programs that may provide personalized, individualized treatment with reduced staff burden e.g., 24. Other reported treatment barriers included shame, disinterest, and health-related problems. The diversity of reported treatment obstacles suggests assessment of these barriers should occur during initial treatment planning sessions. This may result in increased MH utilization and foster active treatment engagement amongst Veterans. Findings from open-ended questions in the present study can help develop a structured measure of treatment barriers for this population.
In the present study, the PHQ-2 appears to be an adequate screening instrument to identify those in need of MH services. When PHQ-2 scores were not taken into consideration, current self-report of depressive symptoms was the only independent correlate of MH treatment participation. Both methods therefore indicated depressive symptomatology was the most potent predictor of MH service utilization. This may be because reporting depressive symptoms results in the provision of MH services. It may also be that the SPID clinic screens depressive symptoms more routinely than other MH symptoms. Worth noting is that over a quarter of older HIV+ Veterans not engaged in treatment still endorsed depressive symptoms, as well as anxiety and stress, and a proportion had yet to be offered services. These findings highlight the need to screen for MH symptoms in this Veteran group with high healthcare needs. The inclusion of MH screenings at infection disease and primary care clinics may ensure that the psychological needs of HIV+ older adults are identified and treated. According to the American Psychological Association25, four out of five individuals with HIV do not receive effective MH treatment, largely due to “one-size-fits-all” systems of healthcare which are inadequate in meeting the complex needs of those aging with HIV. Our data indicate a larger proportion of HIV+ Veterans are receiving treatment than this national average, and of those not receiving treatment the majority feel the VA has the resources necessary. The VA’s integrated healthcare model is a strong environment in which to advance this issue, and continued efforts to integrate primary health care, geriatricians, HIV providers, and MH treatment may address the complex needs of this growing population 25. Comprehensive assessment and integrated health care planning in this population is necessary and has already been identified as a priority area by VA 26.
The present study had several limitations. As our survey was administered anonymously, age was the only demographic characteristic collected. Thus, we cannot characterize our sample in terms of other important factors, such as gender, education level, socioeconomic status, and race/ethnicity. There might be important differences among subgroups of older Veterans that are yet to be discerned. Additionally, substance abuse was not evaluated, despite the high rates of abuse within this population. While we used a validated measure to assess depressive symptomatology, we did not include validated measures of anxiety and stress to keep the burden on the participants and SPID clinic staff low. Nonetheless, we found some useful information that could be followed-up with a more thorough set of measures (e.g., Beck Anxiety Inventory (BAI); Perceived Stress Scale (PSS)). Another limitation is that the survey did not assess the modality of MH treatment that Veterans were offered or participated in (e.g. whether participants were receiving psychotherapy, psychopharmacology, or a combination of both). Lastly, all data were collected via participants’ self-report. Future studies should also include objective assessments, such as chart reviews, in order to better understand the MH needs of this population.
Conclusions
Comprehensive and integrated care models are necessary given the large number of Veterans with comorbid HIV and MH needs. Efforts to combat HIV and MH stigma and to integrate primary health and mental health care at Infectious Disease or General Medicine clinics will likely improve the overall well-being in persons living and aging with this disease. Additionally, the use of telehealth and/or mobile health technology may decrease the barriers for associated with MH treatment.
Clinical Points.
Older Veterans with HIV face numerous behavioral health problems, and there is a need to better engage these Veterans in mental health treatment.
Older Veterans with HIV+ reporting depressive symptoms are more likely to participate in mental health treatment than Veterans reporting other behavioral health problems.
Primary reported barriers to mental health treatment included scheduling/availability, travel time and transportation, and discomfort with group settings.
Acknowledgments
Sources of Funding:
Salary support for this research was supported, in part, by the National Institute on Mental Health under grant numbers K23 MH107260 (RCM), K23 MH105297 (MJM), and T32 MH019934 (RCM). Salary support for DMS was provided by VA RR&D MERIT 1 I01 RX001691–01A1.
Footnotes
Disclosures: No conflicts of interest were declared.
Previous Presentation: These data were presented October 2014 at the 18th annual United States Conference on AIDS, San Diego, CA.
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