1. Depression, Sexually Transmitted Infection, and Sexual Risk Behavior among Young Adults in the United States
MR Khan, JS Kaufman, BW Pence,
BN Gaynes, AA Adimora, SS Weir, WC Miller
National Development & Research Institutes, NY, NY
University of North Carolina, Chapel Hill, NC
Duke University, Durham, NC
2008 National STD Prevention Conference – Chicago, IL
March 13, 2008

2. Depression and STI or Related Sexual Risk Behaviors
Depression associated with odds of:
STI (Ramrakha S. 2000, Shrier L. 2001)
Multiple partnerships (Kosunen E. 2003)
Unprotected sex (Ramrakha S. 2000)
Early onset of sex (Kaltiala-Heino R. 2003, Hutton H. 2004)
Depression inconsistent predictor of STI
Nationally-representative adolescent sample (Shrier L. 2002)
Depressed boys had >3 times levels of STI one year later
Depressed girls did not have higher STI levels
Baltimore sample of drug users (Williams C. 2005)
Depression associated with modest increases in STI

3. Depression and STI: Theory
Disrupted self-regulation
Maladaptive behaviors
Emotional reactivity in relationships ? ?
Substance Use ?
Sexual risk behavior &
STI
References: Aseltine 1994, Crepaz 2001, Beck 2003, Rao 2006

4. Methods

5. The National Longitudinal Study of Adolescent Health (Add Health)
Prospective cohort study
Nationally-representative
Wave I (1995)
In-home questionnaire (N=20,724)
Wave III ( )
In-home questionnaire (N=14, 322)
Bio-specimen collected and testing for Chlamydia trachomatis, Neisseria gonorrhea, or Trichomonas vaginalis

6. Current Study: Aim & Sub-Population
Depression Timing and Duration
(Wave I, III)
Biologically-confirmed STI
Multiple sexual partnerships
Inadequate condom use
(Wave III)
Analytic sample:
Complete sample weight variables
Non-missing STI data & depression data
N = 2298 black/Latina women
N = 1970 black/Latino men
N = 3337 white women
N = 2940 white men

7. Exposure Assessment (1)
Center for Epidemiologic Studies (CES-D)
Modified scale = 9 items measure symptoms past week
Identified cut-point for symptoms suggestive of major depression
Calculated depression score for:
Adolescence (Wave I)
Adulthood (Wave III)
Identified if respondent had depression in adolescence, adulthood, or both

8. Exposure Assessment (2)
Depression timing and duration
Chronic Depression in adolescence (Wave I) & adulthood (Wave III)
Recent Depression in adulthood only (Waves III)
Prior Depression in adolescence only (Wave I only)
None Depression history (neither Wave I, nor Wave III)

9. Outcome Assessment 1. Wave III biologically-confirmed infection with
Chlamydia trachomatis, Neisseria gonorrhea, or
Trichomonas vaginalis
(yes versus no)
2. Multiple partnerships (past year)
3. Never used condom during sex (past year)

10. Stratification Variables
1. Gender
(men versus women)
2. Race/ethnicity
(white versus black/Latino)

11. Multivariable Modeling
Exposure: Depression
Outcomes: STI & sexual risk behaviors
Stratification variables: Gender, race/ethnicity
Gender-specific logistic regression for survey data
Depression*minority interaction term
Unadjusted OR: Depression and STI/risk behavior
Adjusted ORs: Depression and STI
Respondent adolescent STI status (Wave I)
Respondent age
Socio-economic indicators: Respondent income, mother’s education
Confounding by substance use explored

12. Results

13. Adult STI (Wave III) by Race/ethnicity
Overall STI Prevalence: 6%
% STI
Black/Latina women
16%
Black/Latino men
12%
White women 4%
White men 3%

14. Depression in Adolescence (Wave I) and Adulthood (Wave III) by Race/ethnicity
MDD Timing and Duration
Prior depression (Wave I only)
12%
Recent depression (Wave III only) 7%
Chronic depression (Waves I & III) 5%
Total: Ever had depression
24%
Black/Latina women: 36%
Black/Latino men: 24%
White women: 27%
White men: 16%

15. Black/Latina Women: Depression & Adult STI Adjusted for Socio-demographics & Adolescent STI
Prior Depression
Recent Depression
Chronic Depression
Odds Ratio
Further adjustment for substance use in adolescence: OR=1.4, 95% CI:

16. Multiple Partnerships Never Used Condoms During Sex
Black/Latina Women: Depression & Adult Sexual Risk Behaviors Unadjusted
Multiple Partnerships
Never Used Condoms During Sex
Prior Dep
Recent Dep
Chronic Dep
Prior Dep
Recent Dep
Chronic Dep
Odds Ratio

17. Black/Latino Men: Depression & Adult STI Adjusted for Socio-demographics & Adolescent STI
Prior Depression
Recent Depression
Chronic Depression
Odds Ratio
Further adjustment for substance use in adolescence: OR=2.1, 95% CI:

18. Black/Latino Men: Depression & Adult Sexual Risk Behaviors Unadjusted
Multiple Partnerships
Never Used Condoms During Sex
Prior Dep
Recent Dep
Chronic Dep
Prior Dep
Recent Dep
Chronic Dep
Odds Ratio

19. White Women: Depression & Adult STI Adjusted for Socio-demographics & Adolescent STI
Prior Depression
Recent Depression
Chronic Depression
Odds Ratio

20. White Women: Depression & Adult Sexual Risk Behaviors Unadjusted
Multiple Partnerships
Never Used Condoms During Sex
Prior Dep
Recent Dep
Chronic Dep
Prior Dep
Recent Dep
Chronic Dep
Odds Ratio

21. White Men: Depression & Adult STI Adjusted for Socio-demographics & Baseline STI
Prior Depression
Recent Depression
Chronic Depression
Odds Ratio

22. Add Health Summary & Public Health Implications (1)
Depression STI among minorities
Strongest associations between depression and STI
Minority men: Chronic depression
Minority women: Adolescent depression
Low condom use likely contributes to STI among depressed
Race differential in STI diagnosis and treatment
Integration of programs for mental health, substance use, and STI needed
Minorities communities should be prioritized

23. Add Health Summary & Public Health Implications (2)
Depression Sexual behaviors among white women
Sexual risk behavior did not translate to higher STI levels
Potential for infection spread given risk behaviors

24. Limitations Unable to conduct a strictly longitudinal analysis
Substance use – treated as a confounder but may be a mediating variable
Depression measurement may not be sensitive, specific

25. Further Study
Add Health Wave IV
Chronic depression  Adulthood STI

26. Acknowledgements
Behavioral Sciences Training in Drug Abuse Research Postdoctoral Fellowship
Sponsors: Medical and Health Research Association of New York City and NDRI
Funding: National Institute on Drug Abuse (NIDA Grant # 5T32 DA07233).