Sage Journals: Discover world-class research

Abstract

The purpose of this study was to evaluate the prevalence of depressive symptoms and associated variables among people living with HIV/AIDS (PLWHA) in a specialized treatment center in a city located in southern Brazil. A cross-sectional study was conducted using the Beck Depression Inventory to assess the presence of depressive symptoms. The prevalence of depressive symptoms was 53.5% among the surveyed population, which supports the idea that depressive symptoms are more common among PLWHA, mainly if compared with the general population. It was observed that 57.7% of the study participants were with depressive symptoms and did not take any psychiatric medication and 100% did not undergo psychotherapy, which indicates undertreatment. There was no statistically significant difference in the mean CD4 count between patients with depressive symptoms (484.1 ± 353) and patients without depressive symptoms (528.4 ± 263). Further actions should be taken to improve the care for PLWHA. The interface between psychology, psychiatry, and internal medicine is of utmost importance to provide a more humanized care, in which the psychosocial, psychological, and psychiatric aspects are not neglected.

Keywords

HIV/AIDS depressive symptoms beck depression inventory mood disorders

Introduction

The estimated prevalence of major depressive disorder in the general population is approximately 10% to 25% for women and from 5% to 12% for men. Projections indicate that by the year 2020, major depression will be the second largest cause of disability and death worldwide.¹

Epidemiological studies of depression in clinical diseases are even more worrying, since depression occurs frequently among patients with diabetic patients,² after acute myocardial infarction,³ and in individuals with cancer.⁴ Prevalence rates of depression in PLWHA vary between 20% and 79%, depending on the population studied, the period investigated, and the tools used to define the patients.^5
–7 The assessment of depression symptoms in individuals living with HIV/AIDS must be done carefully and should take into account the stages of the disease, because some debilitating physical symptoms can fudge depression indicators.⁸ Likewise, attention should be paid to the fact that some antiretroviral (ARV) drugs can cause symptoms similar to those found in depression.⁹ There is also the HIV-associated dementia that may be misdiagnosed as depression, so the differential diagnosis must be performed.^10,11

This study aimed to assess the prevalence of depressive symptoms among PLWHA and the factors associated with this condition.

Methods

A cross-sectional study was conducted between March and May 2011 in a reference service assisting PLWHA in a city in Southern Brazil. The study enrolled patients aged 18 years or older who were living with HIV/AIDS. Those who had a diagnosis of dementia and those who did not agree to participate by signing the consent form were excluded. The Mini-Mental State Examination was used for dementia detection.¹² A questionnaire was administered to detect the abuse of alcohol or drugs,¹ and the Beck Depression Inventory (BDI) was used to assess the presence of depressive symptoms.¹³

For the collection of other variables, the medical records of patients were consulted on the day of blood collection for CD4 count and viral load determination in peripheral blood. The variables studied included the degree of depressive symptoms (minimal, mild, moderate, and severe), gender, age, ethnicity, household income, educational level of participants, time elapsed since HIV diagnosis, CD4 count in peripheral blood, beginning of ARV treatment, disease stage, continuous use of psychiatric medications, and others.

The research project was submitted to and approved by the Human Research Ethics Committee at the University of Southern Santa Catarina (UNISUL, Brazil) under the code number 11.067.4.01.III.

The results were summarized as absolute numbers and percentages and means and standard deviations (SDs), and the independent variables were compared between individuals with depressive symptoms and individuals without them, using the chi-square test at the 5% significance level.

Results

In total, 249 individuals attended for a CD4 count and viral load measurement during the surveyed period, of whom 212 agreed to participate. From these, 9 patients were excluded, because they had dementia, accounting for a 4.2% loss (Figure 1).

Figure 1.

Flowchart showing the number of people surveyed and exclusions. The data compiled by author.

The age of participants ranged between 18 and 74 years, mean age was 42.4 (SD ± 11.1) years, 109 (53.7%) were male, and 167 (82.3%) were caucasians. With regard to marital status, 66 (32.5%) were married, 12 (5.9%) were divorced, 8 (3.9%) informed that they were separated, 99 (48.8%) were single, and 17 (8.4%) were widowed. Marital status was not reported by 1 (0.5%) participant. With regard to household income, 31 (15.2%) reported an income less than a minimum wage (US$ 334), 135 (66.5%) said they earned between 1 and 3 minimum wages, and 30 (14.8%) earned more than 3 minimum wages. Most participants (32.5%) had incomplete primary education.

In all, 26 (12.8%) participants had CD4 count lower than 200 cells/mm³ and 177 (87.2%) had a count ≥200 cells/mm³. CD4 count ranged from 21 to 2493 cells/mm³, with a mean of 507 cells/mm³ (SD ± 314.7). With regard to the viral load, 129 (63.5%) participants had a viral load ≤50 copies/mL, and 74 (36.5%) had a viral load greater than 50 copies/mL. Viral load count ranged from 50 to 397 946 copies/mL, with a mean of 11 017.6 (SD ± 40 377.7) copies/mL.

With regard to the time elapsed since HIV diagnosis, the length ranged from 1 to 26 years, with a mean length of 7.2 years (SD ± 5.4). Regarding the disease stage, 93 (45.8%) were in stage 1 of the disease, 84 (41.4%) were in stage 2, and 26 (12.8%) were in stage 3. In all, 154 (75.9%) participants reported that they were taking antiretroviral therapy (ART). The length of time under treatment ranged from 1 to 20 years, with a mean of 5.9 years (SD ± 4.4). Regarding the symptoms indicative of depression as assessed by BDI, 109 (53.7%) participants were classified with depressive symptoms, and 94 (46.3%) as without them. The BDI scores ranged between 0 and 52, with a mean score of 16.6 (SD ± 14). The distribution of the participants according to the BDI scores is shown in Table 1.

Table 1.

Distribution of the Study Participants According to BDI Scores.

BDI Scores	n	%
Severe	27	13.3
Moderate	46	22.7
Mild	36	17.7
Minimal	94	46.3
Total	203	100

Abbreviation: BDI, Beck Depression Inventory.

With regard to the use of psychiatric medications, 146 (71.9%) participants did not use any of them. None of the surveyed patients reported that they were undergoing some type of psychotherapy. In relation to psychoactive drug abuse, 27 (13.3%) patients fulfilled the criteria for substance abuse. With respect to other medications, 127 (62.6%) patients did not use any medications, 73 (36%) used some, and 3 (1.5%) did not respond.

Table 2 shows the distribution of data according to the presence or absence of depressive symptoms.

Table 2.

Distribution of Variables According to the Presence or Absence of Depressive Symptoms.

Variable	Presence of Depressive Symptoms, n (%)	Absence of Depressive Symptoms, n (%)	P
Gender
Female	54 (49.5)	40 (42.6)	.196
Male	55 (50.5)	54 (57.4)	.196
Ethnicity
Caucasian	91 (83.5)	76 (80.9)	.379
Noncaucasian	18 (16.5)	18 (19.1)	.379
Marital status
Married	34 (31.2)	32 (34.0)	.886
Divorced	6 (5.5)	6 (6.4)
Separated	5 (4.6)	3 (3.2)
Single	54 (49.5)	45 (47.9)
Widowed	9 (8.3)	8 (8.5)
Not informed	1 (0.9)	–
Household income
1-3 minimum wages	70 (64.2)	65 (69.1)	.703
<1 minimum wages	19 (17.4)	12 (12.8)
>3 minimum wages	16 (14.7)	14 (14.9)
Not informed	4 (3.7)	3 (3.2)
Level of education
Illiterate	1 (0.9)	–	.660
Elementary school	29 (26.6)	24 (25.5)
Incomplete elementary school	38 (34.9)	28 (29.8)
High school	18 (16.5)	25 (26.6)
Incomplete high school	6 (5.5)	5 (5.3)
College degree	11 (10.1)	6 (6.4)
Incomplete college degree	3 (2.8)	3 (3.2)
Not informed	3 (2.8)	3 (3.2)
CD4 cutoff point, cells/mm³
<200	16 (14.7)	10 (10.6)	.259
≥200	93 (85.3)	84 (89.4)	.259
Viral load, copies/mL
≤50	66 (60.6)	63 (67.0)	.209
>50	43 (39.4)	31 (33.0)	.209
Disease stage
Stage 1	44 (40.4)	49 (52.1)	.489
Stage 2	49 (45.0)	35 (37.2)
Stage 3	16 (14.7)	10 (10.6)
Use of antiretroviral
No	30 (27.5)	19 (20.2)	.147
Yes	79 (72.5)	75 (79.8)	.147
Use of psychiatric medication
No	63 (57.8)	83 (88.3)	.000
Yes	46 (42.2)	11 (11.7)	.000
Use of other medications
No	66 (60.6)	61 (64.9)	.580
Yes	42 (38.5)	31 (33.0)
Not informed	1 (0.9)	2 (2.1)
Substance abuse
No	91 (83.5)	85 (90.4)	.106
Yes	18 (16.5)	9 (9.6)	.106

There was no statistically significant difference in the mean CD4 count between patients with depressive symptoms (484.1 ± 353) and patients without depressive symptoms (528.4 ± 263; P = .160).

Tables 3 and 4 show the distribution of the participants according to the use of ARV therapy, viral load, TCD4 count, and the presence or absence of depressive symptoms.

Table 3.

Distribution of Participants According to the Use of ARV, Viral Load, and the Presence or Absence of Depressive Symptoms.

Viral Load	Depressive Symptoms
Viral Load	No	Yes	Total
≤50^a
ARV
No	2 (3.2%)	5 (7.6%)	7
Yes	61 (96.8%)	61 (92.4%)	122
Total	63	66	129
>50^b
ARV
No	17 (54.8%)	25 (58.1%)	42
Yes	14 (45.2%)	18 (41.9%)	32
Total	31	43	74

Abbreviation: ARV, antiretroviral.

^a P = .441.

^b P = .815.

Table 4.

Distribution of Participants According to the Use of ARV, TCD4 Counts, and the Presence or Absence of Depressive Symptoms.

CD4 Cutoff Point	Depressive Symptoms
CD4 Cutoff Point	No	Yes	Total
<200^a
ARV
No	2 (3.2%)	5 (7.6%)	7
Yes	61 (96.8%)	61 (92.4%)	122
Total	63	66	129
≥200^b
ARV
No	17 (54.8%)	25 (58.1%)	42
Yes	14 (45.2%)	18 (41.9%)	32
Total	31	43	74

Abbreviation: ARV, antiretroviral.

^a P = .492.

^b P = .159.

Discussion

Prevalence of depressive symptoms in this population was found to be 53.5%, which supports the idea that depression is more common in PLWHA, mainly if compared with the general population. The prevalence of depression in PLWHA ranges from 20% to 79%. According to several studies, this difference can often be attributed to the population studied, surveyed period, and tools used to identify cases of depression.^5,7

In this study, there was no statistically significant association between the presence of depressive symptoms and gender. Epidemiological data in the general population show that depression is more common in women than in men.^1,14 Justo and Calil¹⁵ hypothesize that the causes for this difference can be related to hormonal and sociocultural aspects. No data were found in the literature that discussed the possible causes for the differences in findings in this specific population compared to those found in the general population. Perhaps in this case, living with HIV/AIDS could have an equal impact on the triggering of depressive episode, both in men and in women.

If we compare the higher rates of depression in individuals with other clinical pathologies than in those living with HIV/AIDS, we will also see that the former is significantly more numerous than the latter. High rates of depression are observed in diabetic patients,² in patients with postmyocardial infarction,³ and in persons with cancer.⁴ So, it is evident that the diagnostic investigation of depression in people with HIV/AIDS should not be neglected.

There are studies showing that depression is a risk factor for nonadherence to ART and that antidepressant treatment improves adherence rates. As a consequence, the increase in TCD4 is stimulated.^16
–18

All patients diagnosed with depressive disorder should be treated with psychotherapy and/or psychotropic medications, including depression symptoms in PLWHA.¹⁹ In the present study, 57.8% of the patients with depression symptoms neither used psychiatric medication nor underwent psychotherapy.

In this study, no statistically significant differences were found in TCD4 counts and viral load between individuals with depressive symptoms and individuals without them. Published studies are controversial when examining these conditions. Some authors report that patients with lower TCD4 counts have a higher percentage of depression^17,20; however, Lyketsos et al did not observe this finding.²¹

Studies show that ART increases TCD4 counts,¹⁷ and most (76%) individuals in this study were taking ARV drugs. However, the present study found no statistically significant difference between individuals with depressive symptoms and individuals without them, even when examining TCD4 counts in participants who were not receiving ART. Although there are reports of higher evolution in disease progression among depressed patients,^17,22,23 in this study there was no association between the disease stage and the use of ART in patients with and without depressive symptoms. This was a cross-sectional study, which generates, by definition, just 1 observation. Cohort studies and control confounding variables could contribute better to the elucidation of these controversies.

In this study, there was no association between these variables ethnicity, marital status, household income, education, and presence or absence of depressive symptoms. Research evaluating the prevalence of depression and associated characteristics in the general population,²⁴ and PLWHA,²⁵ did not show an association between these variables and the presence or absence of depression.

Time elapsed since HIV/AIDS diagnosis was not significant for increasing the prevalence of depressive symptoms. Assessment of predicting factors for depression in PLWHA showed that the incidence of depression in individuals who had a psychiatric history prior to infection, particularly a history of depression, and HIV-related symptoms, independently of the time elapsed since diagnosis, was higher than in other groups.²⁰

In epidemiological studies performed with drug addicts in the general population, there are significant prevalence rates of other psychiatric disorders.²⁶ The present study found no statistically significant differences of depressive symptoms between drug users and nonusers. This finding may indicate that individuals, when infected, stop doing drugs. The decrease in cocaine use in individuals after receiving a diagnosis of the disease is described in the literature.²⁷

In conclusion, further actions should be taken to improve the care for PLWHA. The interface between psychology, psychiatry, and clinical medicine is of utmost importance to provide a more humanized care, in which the psychosocial, psychological, and psychiatric aspects are not neglected.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSMIV-TR-Text Revision. Washington, DC: American Psychiatric Association; 2000.

Atlantis

Browning

Sims

Kendig

. Diabetes incidence associated with depression and antidepressants in the Melbourne Longitudinal Studies on Healthy Ageing (MELSHA). Int J Geriatr Psychiatry. 2010; 25(7):688–696.

Yary

Soleimanejad

Rahim

Contribution of diet and major depression to incidence of acute myocardial infarction (AMI). Lipids Health Dis. 2010;9:133.

Warmenhoven

van Rijswijk

Engels

The Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in Dutch advanced cancer patients. Support Care Cancer. 2012;20(2):319–324.

Mello

Malbergier

. Depression in women infected with HIV. Rev Bras Psiquiatr. 2006;28(1):10–17.

Farley

Miller

Zamani

Screening for hazardous alcohol use and depressive symptomatology among HIV-infected patients in Nigeria—prevalence, predictors, and association with adherence. J Int Assoc Physicians AIDS Care (Chic). 2010:9(4):218–226.

Bhatia

Hartman

Kallen

Graham

Giordano

. Persons newly diagnosed with HIV infection are at high risk for depression and poor linkage to care: results from the Steps study. AIDS Behav. 2011;15(6):1161–1170.

Malbergier

Schöffel

. Treatment of depression in HIV-infected individuals. Rev Bras Psiquiatr. 2001;23(3):160–167.

Ferrando

HIV-related mood disorders. In: The Treatment of Psychiatrically Ill HIV Patients. Chicago, IL: American Psychiatric Association; 2000:1–22.

10.

Reis

Haas

Santos

Teles

Galvão

Gir

. Symptoms of depression and quality of life of people living with HIV/AIDS. Rev Lat Am Enfermagem. 2011;19(4):874–881.

11.

Valcour

Shikuma

Shiramizu

Higher frequency of dementia in older HIV-1 individuals: the Hawaii aging with HIV-1 cohort. Neurology. 2004;63(5):822–827.

12.

Folstein

McHugh

. “Mini-Mental State”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198.

13.

Cunha

. Manual da Versão em Português das escalas de Beck. São Paulo, Brazil: Ibneuro; 2001.

14.

Lima

Beria

Tomasi

Conceição

Mari

. Stressful life events and minor psychiatric disorders: an estimate of the population attributable fraction in a Brazilian community-based study. Int J Psychiatry Med. 1996;26(2):211–222.

15.

Justo

Calil

. Depression—does it affect equally men and women? Rev Psiquiatr Clin. 2006;33(2):74–79.

16.

Silveira

Guttier

Pinheiro

Pereira

Cruzeiro

Moreira

. Depressive symptoms in HIV-infected patients treated with highly active antiretroviral therapy. Rev Bras Psiquiatr. 2012;34(2):162–167.

17.

Ironson

O’Cleirigh

Fletcher

Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment. Psychosom Med. 2005;67(6):1013–1021.

18.

Horberg

Silverberg

Hurley

Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients. J Acquir Immune Defic Syndr. 2008;47(3):384–390.

19.

Sherr

Clucas

Harding

Sibley

Catalan

. HIV and depression—a systematic review of interventions. Psychol Health Med. 2011;16(5):493–527.

20.

Atkinson

Heaton

Patterson

Two-year prospective study of major depressive disorder in HIV-infected men. J Affect Disord. 2008;108(3):225–234.

21.

Lyketsos

Hoover

Guccione

Depressive symptoms over the course of HIV infection before AIDS. Soc Psychiatry Psychiatr Epidemiol. 1996;31(3-4):212–219.

22.

Leite

Motta

Junior

Araujo

Pupulin

. Depression, stress and alexithymia in patients with infection by the HIV virus. Acta Sci Health Sci. 2007;29(1):67–71.

23.

Leserman

Jackson

Petitto

Progression to AIDS: the effects of stress, depressive symptoms, and social support. Psychosom Med. 1999;61(3):397–406.

24.

Vorcaro

Uchoa

Lima-Costa

. Prevalence and associated characteristics of depression: a review of population-based epidemiological studies. J Bras Psiquiatr. 2002;51(3):167–182.

25.

Kinyanda

Hoskins

Nakku

Nawaz

Patel

Prevalence and risk factors of major depressive disorder in HIV/AIDS as seen in semi-urban Entebbe district, Uganda. BMC Psychiatry. 2011;11:205.

26.

Rodrigues

. Psychiatric comorbidities in alcohol and drugs dependent subjects. Rev Par Med. 2008;22(2):53–61.

27.

Malbergier

Andrade

. Depressive disorders in injecting drug users infected by the HIV virus: controlled study. Rev Bras Psiquiatr. 1999;21(4):217–224.

Depressive Symptoms and Associated Factors among People Living with HIV/AIDS

Abstract

Keywords

Introduction

Methods

Results

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

References