Future studies of strategies for managing chronic inflammation in HIV may consider using an inflammation burden composite and examining how changes in inflammation burden affect complex motor performance given this neurocognitive domain appears to be more strongly associated with inflammation relative to other domains.People living with HIV experience high rates of mental illness, including elevated rates of depression and anxiety . In the United States , poverty and social deprivation are concentrated among PLHIV , and may contribute to poor mental health. An important challenge that low-income PLHIV in the USA frequently face is food insecurity , which includes food insufficiency and hunger, poor quality diets, persistent uncertainty around access to food and having to engage in personally or socially unacceptable food procurement . Food insecurity has been associated with a range of poor mental health outcomes including depression , anxiety , symptoms of post-traumatic stress disorder , substance use and suicidality . While people who experience mental illness likely face more barriers to accessing healthy food, evidence from longitudinal and qualitative studies indicates that food insecurity contributes to symptoms of common mental illness . Provision of food support to food-insecure individuals in a manner consistent with the preservation of dignity has been shown to reduce symptoms of depression . These findings raise questions about how symptoms of common mental illness occurring in the setting of adverse social and structural factors should be addressed. Mental illness and its treatment are often formulated according to a ‘bio-psychosocial’ model in which multidimensional influences on mental health are addressed concurrently through psychotropic medications, psychological interventions and services aimed at improving social circumstances. Yet, in practice, psychotropic medications often predominate. In the USA, data have shown significant upward trends over the past two decades for the use of psychotropic medications alone, compared to significant downward trends for the use of psychotherapy and psychotropic medications together or psychotherapy alone . One in six US adults is now prescribed a psychotropic medication,industrial vertical farming rising to one in five among non-Hispanic White adults and one in four among adults aged 60–85 years .
Pharmaceutical drugs are prominent for several reasons. Psychotropic medications have the most extensive evidence base among mental health interventions, as their effects can be measured through randomised controlled trials more easily than other forms of intervention. In meta-analyses of trials, common classes of psychotropic medications including antidepressants and antipsychotics show modest but significant therapeutic effects for their respective indications . Prescribing drugs is also less labour-intensive than psychological or social interventions, and often more accessible and time-efficient for service users. In the USA specifically, the market-based structure of the healthcare system may contribute to higher rates of psychotropic medications, which have the financial and promotional backing of for-profit pharmaceutical companies . Conversely, reimbursement rates for non-pharmacological treatments by Medicare have been falling steadily for many years, driving psychologists and other allied professionals away from low-income service users . Furthermore, psychotropic medications adhere to a medical model of intervention that accords with the clinical education of prescribers. The paucity of social science training in clinical curricula leaves clinicians lacking the intellectual tools and frameworks to fully understand how social-structural issues may drive distress . Consequently, social interventions may be placed at lower priority than pharmaceutical drugs by default, principally through unfamiliarity and misunderstanding on the part of clinicians. The vulnerability of public funding for social support to changes in fiscal policies and political ideologies may also contribute to the primacy of pharmacologic interventions. In the USA, public spending on social safety net institutions has undergone a sustained reduction since the 1980s . The welfare reforms of 1996 had a particularly detrimental effect on the provision of social support, significantly curtailing access to government income for non-disabled adults, with the most severe restrictions targeting those without dependent children . Notably, this development has left federal disability income as one of the last forms of substantial government assistance available to many indigent adults in the USA . Recent studies have suggested that this shift may be fuelling a ‘medicalisation of poverty’, as diagnoses of chronic illness – and particularly mental illness – play an increasingly important economic role for struggling adults to obtain income security through disability status .
In this respect, diagnoses of mental illness, accompanied by treatment with psychotropic medications, can act as an important gateway to a level of income stability otherwise unobtainable for many in the current US context of widespread working poverty under welfare reform . Identifying these social and economic realities does not imply that disabled individuals are malingering, or that clinicians are prescribing for non-clinical reasons, but suggests instead that we consider the impact, at a population level, of structural factors that incentivise the prescription of psychotropic drugs for socially deprived individuals. These arguments raise the question of whether social adversity might drive higher rates of psychotropic prescriptions, independent of psychiatric symptoms. Few empirical studies have attempted to investigate this possibility. We used data from the Women’s Interagency HIV Study , an ongoing prospective cohort study at nine sites across the USA, to investigate the associations between food insecurity and psychotropic medication use among a broadly representative population of women living with HIV in the USA. Our previous studies in the WIHS cohort have demonstrated dose–response relationships between food insecurity and poor mental health outcomes, including depression , anxiety, stress, symptoms of post-traumatic stress disorder , substance use and mental health-related quality of life . Here we used a cross sectional sub-sample of the WIHS cohort for which data on psychotropic medication use were available to test two successive hypotheses: food insecurity would be associated with psychotropic medication use in a dose–response relationship among women living with HIV, mirroring the dose–response relationships between food insecurity and symptoms of common mental illness found in previous studies; and if we additionally adjusted for symptoms of common mental illness, any positive associations between food insecurity and psychotropic medication use would remain significant.Our study was a cross-sectional analysis of data from the WIHS, a prospective cohort study of HIV-seropositive women and demographically similar HIV-seronegative women in the USA. Cohort recruitment, demographics and retention are described elsewhere . WIHS participants undergo structured interviews and physical examinations every 6 months at nine sites across the USA and have blood and other biological samples taken.
Beginning in 2009, a standardised and detailed neurocognitive assessment was added to the WIHS Core exams and administered every 2 years. From April 2013 through March 2016, the Food Insecurity Sub-study collected data every 6 months on food security, nutrition and other key socio-economic variables from all WIHS participants. For the current analysis, women living with HIV who participated in the Food Insecurity Sub-study from April 2013 through March 2015 and also had neurocognitive and psychiatric variables during the same time period were included . Data collection for psychotropic medication use was staggered across four WIHS visits during this period, at five study sites: San Francisco, CA; Chicago, IL; Washington, DC; Bronx, NY and Brooklyn, NY.The primary outcomes were four categories of prescribed psychotropic medication use . WIHS participants are asked to bring a list of medications to each visit and are also asked specifically whether they are using any medications ‘for psychological conditions or depression’ and for the name of the medication. Self-reported psychotropic medications were coded as antidepressants ,vertical agriculture farming sedatives/hypnotics/tranquilisers/anxiolytics or antipsychotics as appropriate. Using these data, we constructed a pooled outcome for any psychotropic medication use and made three separate binary outcomes corresponding to each individual drug class. Other outcomes included symptoms of depression, generalised anxiety disorder and mental health-related quality of life. Symptoms of depression were measured using the Center for Epidemiologic Studies Depression score, a widely used self-report instrument that asks participants how often they experience symptoms of depression including low mood, low self esteem, poor concentration, sleeping difficulties, poor appetite and others . Scores range from 0 to 60, with higher scores indicating greater depressive symptoms. CESD score is a core WIHS study measure collected from WIHS participants at each visit. The internal consistency of the CESD in our sample was high . We measured symptoms of generalised anxiety disorder using the Generalised Anxiety Disorder-7 scale, a 7-item self-report instrument used to screen for and categorise the severity of GAD in primary care . Participants were asked how often they experience symptoms of GAD including worry, restlessness, irritability and others, with responses scored from 0 to 21. In the WIHS, collection of GAD-7 data only began in October 2013. GAD-7 data were therefore only available for approximately 75% of the women participating in our study. The internal consistency of the GAD-7 in the sample was high . Mental health-related quality of life was measured using the Mental Health Summary score of the Medical Outcomes Study HIV Health Survey scale . The MOS-HIV scale, a widely used quality of life measure developed and validated among PLHIV, comprises 35 questions across ten domains, providing a total score out of 100. The MHS is calculated from the total MOS-HIV score by means of a standardised method that transforms the scores of relevant domains into a standardised t-score with a mean of 50 and standard deviation of 10. MHS is a continuous variable composed of four sub-scales where lower scores indicate worse mental health-related quality of life and higher scores indicate better mental health-related quality of life . WIHS participants undergo the MOS-HIV annually . Since psychotropic medication data were staggered across four study visits , MHS data were only available for approximately 50% of the women contributing data to this study.
The internal consistency of the MHS was 0.80.Data were obtained from WIHS visits at which women both completed the HFSSM and had coded psychotropic medication data available, creating a cross-sectional sample staggered over four study visits . Initially, we examined associations of FS with common mental illness to confirm whether the dose–response relationships found in previous studies were reproduced in this sub-sample. To examine associations of FS with CESD score, GAD-7 score and MHS score, we ran multi-variable linear regressions. Next, we tested associations between FS and psychotropic medication use in two successive models. First, we ran multi-variable logistic regressions to examine associations of FS with any psychotropic medication use and antidepressant, sedative and antipsychotic use individually, adjusting for race/ethnicity, income, education, heavy drinking and illicit substance use. For any psychotropic medication use, antidepressant use and sedative use, we then ran multi-variable logistic regressions also adjusted for CESD score and GAD-7 score . We did not include antipsychotic use as an individual outcome in this fully adjusted model because depression and anxiety are not clinical indications for antipsychotic use, which would render the outcome difficult to interpret . The area under the receiver operating characteristic curve, which ranges from 0.5 to 1.0 , was used to quantify how well the models explained the outcomes . All analyses were completed using Stata version 14 .There were 905 women in the sample . Approximately two-thirds identified as African-American, while just under half reported an annual income less than $12 000. Over one-third were categorised as food-insecure . In total, one-third were taking psychotropic medication. The most common class was antidepressants , followed by sedatives and then antipsychotics . In adjusted analyses, compared to high FS, marginal, low and very low FS were significantly associated with increasingly higher CESD and GAD-7 scores and with increasingly lower MHS scores, exhibiting a consistent dose– response relationship across all three outcomes . Of the other variables studied, self-identifying as African American/Black, having an income ⩾$24 001, and having at least a high school education were all variously associated with better mental health . Illicit substance use was associated with higher CESD and GAD-7 scores and lower MHS scores. For the psychotropic medication use outcomes, we first performed adjusted analyses in the absence of adjustment for CESD and GAD-7 scores. We found that marginal and low FS were associated with 2.06 and 1.99 times higher odds of any psychotropic medication use, respectively, compared to high FS . While very low FS was associated with 1.50 times higher odds of any psychotropic medication use, this was not statistically significant. Associations between FS and each individual category of psychotropic medication use exhibited a similar pattern of findings, with the adjusted odds ratios consistently highest for marginal FS.