We conducted the study at the outpatient clinic for HIV and Mental Health at GGZ inGeest in Amsterdam, the Netherlands, between March 2006 and September 2009. This clinic was founded in 1984 and specializes in the assessment and treatment of mental health problems in HIV-infected patients. Patients can be referred to the clinic by their infectious disease specialist, HIV-nurse, family doctor, or regular psychologist or psychiatrist.

New patients visiting the outpatient clinic were asked to participate in this study during their first appointment. The design and the purpose of the study were explained and the patients gave written informed consent. The Medical Ethics Review Committee of the VU University Medical Center approved the research protocol and gave permission for publication.

At the intake, trained staff members obtained a DSM-IV diagnosis by assessment, using the M.I.N.I. International Neuropsychiatric Interview (M.I.N.I. Plus) 25 . Demographic data were recorded and all participants were asked to fill in the assessment lists. The assistant-coordinator of the research program contacted the patients if the assessments lists were not returned. All eligible patients with HIV and mental health problems who gave informed consent and completed the questionnaires were included in the cohort (N = 196).

To compare demographic and clinical characteristics of the cohort of patients from the outpatient clinic for HIV and Mental Health in Amsterdam with the general HIV-positive population of Amsterdam, we selected HIV infected patients from the ATHENA national observational HIV cohort in the Netherlands. ATHENA collects anonymous data obtained during routine clinical care from all HIV-infected patients in the Netherlands who receive care at one of the 25 designated HIV treatment centres 26 . In 2007, the total HIV-infected population collected by ATHENA consisted of 12,570 patients. For the comparison with patients from the outpatient clinic for HIV and Mental Health, we used 5304 HIV-infected patients from Amsterdam.

For the comparison between HIV infected homosexual patients and non-infected homosexual patients, we selected homosexual men with a lifetime dysthymic or depressive disorder from both the original HIV research cohort (N = 84) and the Netherlands Study of Depression and Anxiety (NESDA) (N = 60). NESDA is a longitudinal cohort study that investigates the long-term course of depressive and anxiety disorders. A description of the rationales, methods, and recruitment strategy is reported elsewhere 27 . In this study, DSM-IV diagnoses were obtained using the World Health Organization Composite International Diagnostic Interview (CIDI V 2.1). Although a different diagnostic instrument was used in NESDA than at the intake at the clinic for HIV and mental health, both the CIDI and the MINI assess psychiatric diagnoses according to the DSM-IV classification. Previous studies have shown that diagnoses obtained with the MINI and CIDI were comparable. In the comparison between the MINI and the CIDI the Kappa values were greater than 0.5, except for simple phobia and GAD. Sensitivity was 0.7 or greater for all but four values (panic, agoraphobia, simple phobia, and lifetime bulimia). Specificity was 0.7 or greater for all diagnoses 28 .

Demographics were assessed and patients completed several questionnaires. All respondents signed an informed consent at baseline assessment. A total of 2981 respondents, aged 18–65, were recruited from the general population (19%), primary care (54%) and mental health care organizations (27%) to represent various settings and stages of psychopathology. Selection of homosexual men with a lifetime depressive or dysthymic disorder from the NESDA database yielded a total group of 60 patients without HIV.

The self-report questionnaire was used to obtain measures in three domains: severity of symptoms, personality traits, and substance use. The specific instruments were all part of the NESDA study and allowed us to compare the HIV study participants with the NESDA study participants and included the following assessment lists:

Inventory of Depressive symptoms (IDS) 29 : the 30 item Inventory of Depressive Symptomatology (IDS) is designed to assess the severity of depressive symptoms.

Beck Anxiety Index (BAI) 30 : the Beck Anxiety Inventory (BAI) is a 21-item self-report instrument that assesses the overall severity of anxiety. The BAI was developed to address the need for an instrument that would reliably discriminate anxiety from depression while displaying convergent validity.

Alcohol Use Disorders Identification Test (AUDIT) 31 : the AUDIT identifies persons with hazardous and harmful patterns of alcohol consumption.

NEO Five-Factor Inventory (NEO-FFI) 21 : personality traits of the Five-Factor Module of Personality, Openness (Aesthetic Interests, Intellectual Interests, Unconventionality); Agreeableness (Nonantagonistic Orientation, Prosocial, Orientation); Conscientiousness (Orderliness, Goal-Striving, Dependability); Extraversion (Positive Affect, Sociability, Activity); and Neuroticism (Negative Affect, Self- Reproach).

Fear Questionnaire 32 : the Fear Questionnaire (FQ) is part of a standard brief self-rated form. The complete form also includes one specific main target phobia, a global phobia rating, and five associated anxiety and depression symptoms.

Mood and Anxiety Symptom Questionnaire (MASQ) 33 : the model is based on the assumption that mood can be dissected into two components, negative affect (NA) and positive affect (PA) and a third dimension of somatic arousal (SA). Whereas NA is characterized by aversive emotional states, such as fear, anger, and guilt that are associated with both anxiety and depression, PA represents positive emotional states such as feeling active, excited, delighted, enthusiastic, and interested. A lack of PA is described as feeling ‘tired and sluggish’ and is associated with depressive moods. The SA dimension represents symptoms of physiological hyper arousal, such as trembling, shaking, dizziness, sweating, and heart racing.

Four Dimensional Symptom Questionnaire (4DSQ) 34 : the somatization scale is one of the 4 scales of the Four-Dimensional Symptom Questionnaire, a self-report questionnaire designed to assess common psychological symptoms in primary care.

Women's Health Initiative Insomnia Rating Scale (WHI-IRS) 35 : the list consists of five questions concerning sleep in the past month. The five items address trouble falling asleep, waking up during the night, early morning awakenings, trouble getting back to sleep after waking up, and sleep quality. Although developed by the WHI, the items of this instrument are not sex-specific.

The five screening items of the Beck Scale for Suicide Ideation (BSS) 36 : the BBS is a valuable tool for clinicians to examine suicidal intent in patients. Developed for use with patients of 17 years and up, the BSS provides a good starting point for a clinician's more detailed examination of a patient's suicidal intent.

All statistics were performed using SPSS 15 (SPSS Inc, Chicago, Illinois, USA). The three analyses done are 1) Effect of the duration of HIV; 2) Comparison with ATHENA; and 3) Comparison with depressed homosexual men from NESDA. We used ANOVA to compare group means of continuous variables and the Pearson chi-square statistic to test for differences between groups on discrete variables. When cells had an expected count less than 5, the likelihood ratio is reported instead of the Pearson chi-square statistic.

When comparing HIV-infected and non-infected depressive homosexual patients, several covariates were entered in the statistical model. A particularly important covariate was the clinical setting. It seems likely that patients who seek help for current mental health problems show more symptoms of depression and anxiety than those who do not seek help or are in remission. While all HIV-positive patients had been referred to the mental health clinic for their mental health problems, this was only true for 42% of the HIV-negative depressed subjects. Other covariates that we adjusted for were Dutch origin, age, partner, and work status. Adjustments were done with linear regression analysis for continuous outcomes, and logistic regression for dichotomous variables.

Between March 2006 and September 2009, 291 new patients visited the outpatient clinic for HIV and Mental Health. 56 patients were excluded from the study because they either had no HIV-infection, could not read and write Dutch, or had not completed the diagnostic interview. Another 39 patients refused, leaving a total of 196 patients who participated in the study. Non-responders were more often of a non-Dutch origin (42% vs. 26%, p = 0.043) and were less likely to have a partner (32% vs. 49%, p = 0.051). No differences were found on other demographics or DSM-IV diagnoses.

The demographic characteristics of the HIV-infected patients seeking treatment are listed in Table 1. We could not obtain all demographic characteristics from each patient. Respondents had a mean age of 42 and the mean age at which the HIV-infection was diagnosed was 35.The majority of the patients were homosexual men (77.5%), 49% of the patients had a partner, and 60% had a paid job for more than 12 hours per week. Most patients (68%) had a history of psychiatric treatment before they came to the outpatient clinic. The majority of the patients had Dutch nationality; however, 26% were not originally from the Netherlands. In total, 29 different original nationalities were represented. The level of education was high, only 7% had only a basic education. The respondents reported heavy drugs use 30 days prior to the assessment: 26% had used cannabis and 27% ecstasy, speed or cocaine and 15% had used more than one type of drug.

* Due to missing values, the N varied from 158 (CD4 count) to 196 in the clinic and from 4406 (CD4 count) to 5304 in the ATHENA cohort.

Most patients (85%) had been infected with HIV for over one year. The average CD4-count was 488; 7% of the patients had fewer than 200 CD4-cells/mm³. We have no systematic information about opportunistic infections or HIV-related tumors. The majority of patients (68%) were on antiretroviral treatment.

We found no difference between the two groups in age of HIV diagnosis; neither did we consider the difference in age of intake relevant. However, our cohort consisted of more men, especially more homosexual men and there were more patients of Dutch origin. More patients were within the first years of their infection, and fewer patients were using antiretroviral medication, but no substantial difference appeared in the mean number of CD4-cells, except for the number of patients with more than 500 CD4 cells/mm3

We obtained a DSM-IV diagnosis from 196 patients of the patients included in the study. The results are listed in Table 2. More than 50% of the patients were diagnosed with a major depression disorder, a dysthymic disorder, or a combination of both disorders. Anxiety disorders were less frequently present (21%). 10% of the population was diagnosed with drugs dependence or abuse, but only 5% with an alcohol dependence or abuse. Bipolar and psychotic disorders were not often diagnosed: in total more than 4% of the patients had one of these diagnoses. Adjustment disorders with depressive, anxious, or mixed characteristics were diagnosed in less than 10% of the population. Additional diagnoses like phase of life problem, bereavement or identity problem were determined in more than 30% of the population, usually as an additional diagnosis, sometimes as the main diagnosis.

We divided our patients into four groups, based on the time since their HIV had been diagnosed. The effects of the duration of the HIV-infection are listed in Table 3. Patients who had been infected with HIV for more than ten years were significantly older, were less likely to have a paid job and more often had a history of psychiatric treatment. No differences were found on gender, sexual orientation or having a partner. As expected, the CD4-count first rises and then falls. When it comes to psychopathology, no significant differences were found between the four groups in terms of depressive or anxious symptoms, suicidal ideation and suicide attempts, drug use, or somatization.

¹ ANOVA.

² Pearson chi-square.

³ Chi-square, likelihood ratio.

Due to missing values, the N may vary per item.

The results of the comparison between HIV-positive and HIV-negative homosexual men with a depression or a dysthymic disorder are listed in Table 4. There were no differences between the two groups regarding age, nationality, having a partner, having a paid job or educational level.

* adjusted for clinical setting.

** adjusted for clinical setting, origin, age, partner and work status.

¹ ANOVA.

² Pearson chi-square.

³ Linear regression, ANOVA.

⁴ Logistic regression, Pearson chi-square.

Due to missing values, the N may vary per item.

The patients with HIV were not more depressed or anxious, measured using the IDS, BAI, MASQ positive affect, and Fear Questionnaire. The MASQ negative affect showed more symptoms like fear, anger, and guilt in the HIV-infected patients. The HIV-infected patients showed more suicide ideation, but did not report having committed more suicide attempts. There was no significant difference in alcohol use measured using the total AUDIT-score and in glasses per month. However, the HIV-infected patients drank significantly more standard glasses of alcohol per session. There was a significant difference in the amount of drugs used 30 days prior to assessment. In fact, the HIV-infected patients used more drugs in general: there was a trend for higher scores on use of ecstasy, speed, cannabis, and cocaine.

There was no difference in somatization between the two groups, when measured using the 4DSQ and MASQ and in sleep disturbance measured using the IRS. The results of the NEO showed a mixed pattern: there was a trend for higher scores on the Neuroticism-scale in the HIV-infected population. There were no differences at the Extraversion and Agreeableness scale, but the scores on the Openness scale and conscientiousness scale were significantly lower.