DEPRESSION AND HIV INFECTION: RISK FACTORS FOR CARDIOVASCULAR DISEASE by Jessica Renee White B.S. in Biology, Pennsylvania State University, 2006 M.S. in Bioscience Technologies, Thomas Jefferson University, 2009 Submitted to the Graduate Faculty of the Graduate School of Public Health in partial fulfillment of the requirements for the degree of Doctor of Public Health University of Pittsburgh 2015 UNIVERSITY OF PITTSBURGH GRADUATE SCHOOL OF PUBLIC HEALTH This dissertation was presented by Jessica Renee White It was defended on April 10, 2015 and approved by Matthew Freiberg, MD, MSc, Associate Professor of Medicine, School of Medicine, Vanderbilt University Joyce Bromberger, PhD, Professor of Epidemiology and Psychiatry, Graduate School of Public Health, University of Pittsburgh Chung-Chou Chang, PhD, Professor of Medicine, Biostatistics, and Clinical and Translational Science, School of Medicine and Graduate School of Public Health, University of Pittsburgh Akira Sekikawa, MD, PhD, PhD Associate Professor of Epidemiology, Graduate School of Public Health, University of Pittsburgh Dissertation Advisor: Emma Barinas-Mitchell, PhD, Assistant Professor of Epidemiology, Graduate School of Public Health, University of Pittsburgh ii Copyright © by Jessica Renee White 2015 iii DEPRESSION AND HIV INFECTION: RISK FACTORS FOR CARDIOVASCULAR DISEASE Jessica Renee White, DrPH University of Pittsburgh, 2015 ABSTRACT Depression, a common mental health disorder, is associated with higher risk of cardiovascular disease (CVD). Adults with HIV infection are often burdened with depression. Although both depression and HIV infection are risk factors for CVD, previous studies have not explored how co-occurring depression and HIV are associated with CVD outcomes or underlying physiology. The aim of this dissertation was to (i) measure the risk of incident heart failure (HF) with co- occurring major depressive disorder (MDD) and HIV infection; (ii) measure biomarkers of inflammation, coagulation, monocyte activation, and metabolism with depression and HIV infection; and (iii) provide a comprehensive biomarker profile associated with symptoms of major depression in HIV+ and HIV- participants. We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV+ and HIV- veterans matched on age, sex, race/ethnicity, and geographical region. In a sample of 81,427 participants, we found that those with co-occurring HIV infection and MDD had significantly higher risk of incident HF compared to HIV- participants without MDD, after adjusting for covariates. In a subset of 2,099 participants, we determined that depression was associated with higher concentrations of interleukin-6 and soluble CD14 (biomarkers for inflammation and monocyte activation) in HIV- participants but not HIV+ participants. HIV+ participants had higher concentrations of glucose and triglycerides and lower concentrations of high-density lipoprotein cholesterol with depression. In a smaller sample with more extensive biomarker data, we found a significant iv association between depression and lower concentrations of vascular endothelial growth factor in HIV+ participants. Neither biomarker study supported the hypothesis that co-occurring depressive symptoms and HIV infection would interact and produce excessively high concentrations of these biomarkers. The findings from this dissertation are significant for public health research and practice. Depression is extremely common and is a risk factor for CVD. In the future, investigators must elucidate specific mechanisms driving CVD risk with depression and identify effective therapies for preventing depression-related CVD morbidity and mortality in both HIV- and HIV+ adults. Meanwhile, clinicians must remain vigilant in identifying and managing depressive symptoms, especially among those who are at heightened risk for CVD due to HIV infection. v TABLE OF CONTENTS 1.0 INTRODUCTION ........................................................................................................ 1 1.1 DEPRESSION ...................................................................................................... 1 1.1.1 Pathophysiological mechanisms ..................................................................... 2 1.1.2 Depression and heart failure .......................................................................... 5 1.2 HIV INFECTION ................................................................................................ 9 1.2.1 Pathophysiological mechanisms ................................................................... 10 1.2.2 HIV infection and heart failure .................................................................... 10 1.3 DEPRESSION AND HIV INFECTION .......................................................... 12 1.4 UNANSWERED QUESTIONS ........................................................................ 13 2.0 VETERANS AGING COHORT STUDY ................................................................ 15 2.1 VACS .................................................................................................................. 15 2.2 VETERANS AND DEPRESSION ................................................................... 16 3.0 DEPRESSION AND HIV INFECTION ARE RISK FACTORS FOR HEART FAILURE AMONG VETERANS: VETERANS AGING COHORT STUDY ..................... 18 3.1 ABSTRACT ........................................................................................................ 20 3.2 INTRODUCTION ............................................................................................. 21 3.3 METHODS ......................................................................................................... 22 3.4 RESULTS ........................................................................................................... 26 vi 3.5 DISCUSSION ..................................................................................................... 28 3.6 TABLES AND FIGURES ................................................................................. 32 4.0 ASSOCIATION BETWEEN DEPRESSION AND BIOMARKERS OF INFLAMMATION, ALTERED COAGULATION, MONOCYTE ACTIVATION, AND METABOLISM IN VETERANS WITH AND WITHOUT HIV INFECTION ................... 47 4.1 ABSTRACT ........................................................................................................ 48 4.2 INTRODUCTION ............................................................................................. 49 4.3 METHODS ......................................................................................................... 50 4.4 RESULTS ........................................................................................................... 54 4.5 DISCUSSION ..................................................................................................... 57 4.6 TABLES AND FIGURES ................................................................................. 60 5.0 BIOMARKER PROFILE ASSOCIATED WITH DEPRESSIVE SYMPTOMS IN VETERANS WITH AND WITHOUT HIV INFECTION ................................................ 80 5.1 ABSTRACT ........................................................................................................ 81 5.2 INTRODUCTION ............................................................................................. 82 5.3 METHODS ......................................................................................................... 83 5.4 RESULTS ........................................................................................................... 87 5.5 DISCUSSION ..................................................................................................... 89 5.6 TABLES AND FIGURES ................................................................................. 92 6.0 DISSERTATION DISCUSSION ............................................................................ 101 6.1 MAJOR FINDINGS ........................................................................................ 101 6.2 PUBLIC HEALTH SIGNIFICANCE ............................................................ 102 6.3 FUTURE DIRECTIONS ................................................................................. 104 vii APPENDIX A : LITERATURE REVIEW SUMMARY TABLES: HEART FAILURE .. 105 APPENDIX B : LITERATURE REVIEW SUMMARY TABLES: BIOMARKERS........ 111 BIBLIOGRAPHY ..................................................................................................................... 118 viii LIST OF TABLES Table 3-1 Baseline participant characteristics by HIV status and major depressive disorder (MDD) diagnosis (N = 81,427)* ................................................................................................... 32 Table 3-2 Unadjusted rates of incident heart failure by major depressive disorder (MDD) diagnosis and HIV status (N = 81,427) ......................................................................................... 37 Table 3-3 Cox proportional hazard regression models examining the association between HIV/MDD group and incident heart failure .................................................................................. 38 Table 3-4 Rates and adjusted hazard ratios of incident heart failure among those with baseline MDD (N = 13,849) stratified by HIV and baseline antidepressant use ........................................ 41 Table 3-5 Supplemental Table. List of antidepressants included in study by class* .................. 42 Table 4-1 Comparison between major depressive