Abstract
Background:
Suicidality has rarely been studied in HIV-infected patients in sub-Saharan Africa. This study explored suicidal behavior in a clinic sample of people living with HIV, in Nigeria.
Methods:
Consecutive patients were interviewed using the Composite International Diagnostic Interview (CIDI-10.0) and the World Health Organization Quality of Life (WHO-QOL-HIV-BREF). Associations of suicidal behavior were explored using logistic regression models.
Results:
In this sample of 828 patients (71% female, mean age 41.3 ± 10 years), prevalence of suicidal behaviors were 15.1%, 5.8%, and 3.9% for suicidal ideation, plans, and attempts, respectively. Women were more likely than men to report suicidal ideation (odds ratio 1.7; 95% confidence interval 1.05-2.64). Depression and/or anxiety disorder was associated with increased odds of all suicidal behaviors. Suicidal behavior was associated with significantly lower overall and domain scores on the WHO-QOL.
Conclusion:
Suicidal behaviors were common and significantly associated with the presence of mental disorders and lower quality of life.
Introduction
Suicide and suicidal behavior constitute a huge public health problem worldwide and are projected to become an even greater contributor to disease burden and mortality over the coming decades. 1 HIV, like many other chronic diseases, is associated with an increased risk of suicide and suicidal behavior including suicidal ideation, plans, and attempts. 2 -4 In a recent systematic review of suicidal behavior in HIV-infected individuals, Catalan et al 5 calculated the crude mean prevalence rates for different suicidal behaviors across 66 studies conducted in America or Europe (52 studies), Asia (8 studies), Latin America (2 studies), Australia (1 study), and Africa (3 studies). The crude mean rates for suicidal ideation, plan, and attempts defined as deliberate self-harm were 26.9%, 22.2%, and 19.9%, respectively. 5 This is much higher than the pooled cross-national prevalence rates of 9.2% for ideation, 3.1% for plans, and 2.7% for attempts in the World Mental Health Surveys conducted on the general population in 17 countries from Africa, Asia and the Pacific, Middle East, Europe, and the Americas. 6 In the era before the introduction of highly active antiretroviral therapy (HAART), the risk for completed suicide in the United States was estimated to be 7-fold higher in HIV-seropositive men compared to demographically similar men in the general population. 7 Suicide remains a major cause of death for people with HIV even in this era of HAART. A recent study in the Swiss National HIV cohort revealed that although the suicide rates declined substantially following the introduction of HAART, the rates in the HIV cohort remained well above the national average. 8
Many factors have been associated with the increased risk of suicidal behavior in people with HIV/AIDS. Some researchers have noted a heightened risk among men who have sex with men, which is also the most at-risk population for HIV infection. 9,10 However, this is not enough to account for the excess risk in HIV-infected populations. In addition to commonly reported risk factors for suicidal behavior in the general population such as gender, younger age, social deprivation, mental disorders especially depression, and substance use, 11 there are other factors more specific to HIV status. These include poor social support, fear of disclosure or stigmatization, severity of HIV symptoms, medication side effects, and socioeconomic problems. 9,12
Quality of life (QOL) has become an important measure of medical outcome globally. The World Health Organization (WHO) defines QOL as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. 13 In a longitudinal study based on the Finnish twin cohort, self-reported dissatisfaction with life was associated with a higher risk of suicide throughout a 20-year follow-up period. Previous studies have rarely addressed the impact of individuals’ perception of their QOL on suicidality among people living with HIV (PLWHIV). Haller et al 14 in a study of patients attending an HIV mental health clinic noted that 6 of the 7 quality-of-life variables studied were associated with suicidal ideation.
Recent studies suggest that both current and past history of depression and suicidality have a negative impact on QOL. Poorer health-related QOL is associated with the presence of severe depressive symptoms as well as a history of depression in HIV-positive populations. 15 -17 In a study of patients with bipolar affective disorder, de Abreu et al 18 found that those with a history of suicide attempt regardless of their current mood state had lower scores on all the domains of the WHO-QOL instrument compared to nonattempters. Similar findings have been reported in patients with schizophrenia. 19,20 In a review of the literature on depression, QOL, and HIV, Serafini et al 21 noted a consistent association between major depressive disorder, suicide ideation/thoughts, and poor QOL in persons living with HIV.
Although sub-Saharan Africa has the largest population of PLWHIV, very little of what is known about the intersection of HIV and mental health has emanated from the region. 5 Considering the differences in the demographic, social, and other determinants of the disease in sub-Saharan Africa compared to other regions of the world, it cannot be assumed that findings related to mental health issues can be generalized across regions. Accordingly, in sub-Saharan Africa, there is a need to generate empirical data on mental health aspects of PLWHIV to guide local policies and interventions that will reduce individual suffering and enhance public health. Furthermore, most studies that have examined the suicidal behavior in HIV-infected patients have focused on a particular suicidal behavior (either suicide ideas/thoughts or attempts), and few studies have examined the broad spectrum of suicidal behavior in the same population. In the current study, we determined the rates and the correlates of different suicidal behavior (ideation, plans, and attempts) and examined the associations between a past history of suicidal behavior and QOL scores in a sample of PLWHIV attending an HIV prevention, treatment, and care facility in Nigeria.
Methods
Study Location
This is a cross-sectional study of adult patients enrolled in the AIDS Prevention Initiative in Nigeria (APIN) HIV prevention, treatment, and care facility at the University College Hospital, Ibadan, Nigeria. The clinic has more than 14 000 registered HIV-infected patients, with over 10 000 on antiretroviral therapy.
Sampling and Data Collection
Between March and August 2011, a total of 850 consecutive clinic patients (about 20/day) who were 18 years or older with confirmed HIV diagnosis, were fluent in either Yoruba (the local language) or English, and were not too ill to complete the interview were approached. Of these, 830 consented to take part in the study. Data were collected in face-to-face interviews conducted by 5 trained interviewers, each of whom had a minimum of 3 years postsecondary school education. The interviews were conducted in consulting rooms in the clinic, ensuring patient privacy. Following the interviews, baseline and current CD4 count and viral load were abstracted from the clinic’s electronic database. Ethical approval was obtained from the joint University of Ibadan/University College Hospital Ethical Review Committee. Participants identified as suicidal or as having depression or other mental health problems were counseled and referred to the psychiatry clinic for specialist consultation and appropriate treatment.
Instruments
The WHO’s Composite International Diagnostic Interview (CIDI-10.0) is a fully structured, lay-administered diagnostic interview designed to generate psychiatric diagnosis according to both the
The WHO QOL-HIV Instrument (WHOQOL, 31-BREF) is a cross-culturally applicable tool designed to assess individuals’ perception of their well-being. It is a 31-item instrument that examines QOL across 6 domains: physical, psychological, level of independence, social relationships, and environment and spirituality/religion/personal beliefs. Each domain comprises items that are scored on a 5-point Likert-type scale to generate domain scores that can be summarized to give an overall QOL score. Higher scores denote higher QOL. 25,26
Data Analysis
All data were entered into SPSS and analyzed using version 20.0. Logistic regression models were used to examine the relationship between suicidal behavior (suicidal ideation, plans, and attempts) and patient characteristics (demographic and clinical variables) and QOL. We compared the mean scores for each WHOQOL domain as well as the composite score for all domains (overall score) between participants with and without a history of suicidal behavior. Analysis of variance was used to investigate the differences in mean scores between those with and without suicidal behaviors. Using multivariate logistic models, we assessed associations between a history of suicidal behavior and QOL (overall and domain) after adjustments were made for the occurrence of depression and/or generalized anxiety disorder. The results are presented as odds ratios with their 95% confidence intervals, and we used α = .05 to determine significance.
Results
Demographic and Clinical Characteristics
Two records were discarded due to incomplete data; hence, the final sample for this report is 828. The mean age of the study sample was 41.3 (standard deviation [SD] = 10.0) years, 71% were female, 57.4% were married, and 58.7% completed at least elementary school. Ninety percent of the sample was on ART. Table 1 shows the demographic and clinical characteristics of the sample.
Demographic and Clinical Variables.
Abbreviations: HAART, highly active antiretroviral therapy; SD, standard error;
Suicidal Behavior
The rates for the suicidal behavior since HIV diagnosis were 15.1%, 5.8%, and 3.9% for suicidal ideation, plans, and attempts, respectively. As shown in Table 2, the rates for all suicidal behavior examined were higher in the females; however, this increased rate was significant only for suicidal ideation and was marginal for suicidal plans. Women were twice more likely than men to report suicidal ideation (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.05-2.64) and plans (OR 2.1; 95%CI 0.98-4.59). There was a trend for the rates of suicidal ideation to reduce with increasing age. Other demographic and HIV clinical variables explored did not show any significant association with suicidal behavior.
The Relationship between Suicidal Behaviors and Patient Characteristics (Demographic and Clinical Variables) Using Logistic Regression.
Abbreviations: CI, confidence interval;
aAge as a continuous variable.
Suicidal behaviors were significantly related to the presence of mental disorder. Compared to individuals without a mental disorder, those who met diagnostic criteria for any mental disorder (major depressive disorder and/or generalized anxiety disorder) were 3 times more likely to express suicidal ideas (OR 3.5; 95%CI 2.00-5.98) and 5 times more likely to have suicidal plans (OR 5.1; 95%CI 2.54-10.21) or attempt suicide (OR 5.1; 95%CI 2.42-11.48). When gender and the presence of mental disorders were entered into multiple logistic regression models, only the presence of mental disorders remained as an independent predictor of suicidal behavior: ideation (OR 3.6; 95%CI 2.07-6.24), plans (OR 5.4; 95%CI 2.65-10.81), and attempt (OR 5.3; 95%CI 2.31-11.94; not shown in the table).
Of the 32 who reported having attempted suicide since they were diagnosed with HIV, 29 (90.6%) reported that they actually made a serious attempt to kill themselves, with 21 (65.6%) stating that they required medical attention following the suicide attempt. Considering the methods used, 9 used violent methods, hanging (4), stabbing (1), jumping from a height (2), and crashing their vehicle (2), while 21 used nonviolent methods, poisoning (20) and drug overdose (1). The data for 2 participants were not available.
Suicidal Behavior and QOL Variables
The mean values for QOL were significantly lower in those with suicidal behavior compared to those without suicidal behavior (Table 3). This was consistent across all the 6 domains of QOL assessed in the WHOQOL-HIV: physical, psychological, level of dependence, social relationships, environmental and spirituality/religion/personal beliefs, and the total QOL. However, the weakest associations were for the physical domain of WHOQOL. The mean for overall QOL was 87.9 in those reporting suicidal ideas compared to 94.0 in those without suicide ideation (
Mean Scores on the WHO-QOL-HIV in Patients with or without Suicidal Behavior.
Abbreviations: QOL, quality of life; SD, standard deviation; WHO QOL, World Health Organization Quality of Life.
Considering that QOL scores were most significantly affected by the occurrence of mental disorders in our study, we controlled for this when examining the impact of having had any suicidal behavior on QOL. The results show that suicidal plans and attempts were a significant predictor of lower scores on all domains and overall scores of WHOQOL (Table 4). Suicide ideation was not significantly related to the level of independence and social relationship domains.
The Association between Suicidal Behaviors and WHOQOL Scores Using Odds Ratios from Logistic Regression.a
Abbreviations: CI, confidence interval; OR, odds ratio; WHO QOL, World Health Organization Quality of Life.
aAll figures adjusted for the presence of any depression and/or anxiety disorder.
Discussion
In this study, we determined the rates of different suicidal behavior (ideas, plans, and attempts) in a sample of HIV-infected patients attending an outpatient HIV clinic in Nigeria, a sub-Saharan African country with the second highest burden of HIV globally. We also addressed the impact of QOL and patient characteristics in predicting suicidal behavior. Our main findings were the relatively high rates of different suicidal behavior in this population. Suicidal ideas and plans were significantly more common in women, and the presence of mental disorders was significantly related to higher rates of all suicidal behavior. In addition, patients with suicidal behavior had lower scores on all domains of the WHOQOL compared to individuals without suicidal behavior. Lower scores on all QOL domains acted as a significant predictor of all suicidal behavior.
The high rates of suicidal behavior in this study are similar to findings from other PLWHIVs in different parts of the world. 2,3,5,27 -29 However, compared to an earlier study in the general adult population of Nigeria (the Nigerian Survey of Mental Health and Wellbeing) which used the same instrument, 30 our rates are more than 4 times higher and the demographic pattern is different. Specifically, the rates of suicidal behavior reported in the general Nigerian adult population were 3.2% for suicidal ideas, 1.0% for suicide plans, and 0.7% for attempts 30 compared to our rates of 15.1%, 5.7%, and 3.9% for suicidal ideas, plans, and attempts, respectively. While female HIV-infected patients reported higher rates of suicidal thoughts (suicidal ideas and plans) in our sample, no gender difference was found in the general Nigerian adult population.
Our study confirms that suicidal behavior including suicide attempts remain common problems in the HAART era. 4,31 Attempted suicide is a strong predictor of completed suicide and an indicator of extreme emotional distress, 32 underscoring the need to draw attention to this public health problem. Almost all the participants who attempted suicide in our study stated that the attempt was not just to seek attention but expressed a desire to actually take their own lives with most of them reporting that they required medical attention following the attempts. This troubling finding accentuates the need to integrate comprehensive mental health services into HIV treatment programs in Nigeria.
Although PLWHIV are living longer since the advent of HAART, they have consistently reported lower scores on measures of QOL, 33 an important measure of subjective well-being and satisfaction with life, and there is very little data on the association with suicidality. Studies carried out on the general populations and adults with different mental disorders have shown associations between self-reported QOL and suicidal behaviors. Patients with mood disorders or schizophrenia with a history of suicide attempt have lower scores on all domains of the WHOQOL compared to those without a history of suicide attempts. 18 -20 However, results have been less consistent in identifying the specific domains of QOL that are more likely to predict suicidality. For example, Berlim et al, 34 in a study of patients with mood disorders, reported that those with a history of suicidal ideation had lower scores on the physical, psychological, and social domains on the WHOQOL compared with those without suicide ideation. Goldney et al 35 in a general population study found that suicidal ideation was associated with poorer health-related QOL.
Haller and Miles 14 examined the relationship between suicidal ideas and QOL in a sample of HIV-seropositive patients with comorbid psychiatric disorders. They found that those with suicidal ideation had a poorer QOL across 6 of the 7 domains explored; however, the strongest associations were for measures of social/leisure and family/friends QOL. When the effect of psychiatric morbidity was controlled for in stepwise regression analysis, only social QOL was independently related to suicidal ideation. 14 This is quite similar to our findings that measures of health-related QOL (corresponds to the physical domain on the WHOQOL) had weaker associations with suicidal behavior as opposed to psychological, spirituality/personal beliefs and social relationships. The domains that were strongly related to suicidal behaviors measured factors such as positive and negative feelings, personal relationships, social support and inclusion, forgiveness and blame, death and dying, and concerns about the future. Kalichman et al 36 found that even after controlling for symptoms of depression in a cohort of middle-aged PLWHIV, those with suicidal thoughts perceived that they were receiving less social support from family and friends than those who did not. In accordance with this, studies of patients with mood disorders have demonstrated associations of suicidality with lower scores on the social and psychological domains of QOL regardless of the presence of depressive symptoms. 18,37
Taken together, these findings suggest that suicidal behavior irrespective of the presence of mental disorders worsen QOL, and perceived low QOL possibly increases the risk for further suicidal behavior or even completed suicide. Pompili et al 15 reported that HIV-infected patients with poorer QOL had higher hopelessness levels increasing their risk of suicidality. These associations are worth examining in future longitudinal studies. Furthermore, these findings also highlight the importance of evaluating psychosocial factors in determining the well-being of PLWHIV and in predicting those at risk for suicidal behavior. In most developing countries, treatment programs for PLWHIV struggle to meet the challenges associated with providing HAART, leaving little or no resources to provide psychological interventions.
Our results should be interpreted in the context of some limitations. This study is a cross-sectional survey of patients attending an HIV clinic based in a tertiary health care center, which limits the ability to generalize our findings. It is unknown whether similar results would be obtained in other HIV treatment settings or in community samples of PLWHIV. The suicidal behaviors, mental disorders, and QOL variables are based on retrospective self-report as assessed by the various ascertainment tools hence susceptible to recall errors or bias. Hence, we could not determine causality and whether the lower QOL scores were already present before the suicidal behaviors. Another limitation is that we did not examine the effect of individual antiretroviral medications, especially efavirenz, which has been linked to central nervous system adverse effects and may be associated with depression and suicidality. 38,39 Finally, the proportion of patients on ART in this study (90%) is higher than the national ART coverage, which is approximately 30%. As such, our results may be more representative of settings with broad ART coverage. Studies in settings with lower ART coverage would be informative.
Despite these limitations, our study provides crucial information on suicidal behavior in a population that is underresearched. To our knowledge, no other study has reported on the relationship between QOL and different suicidal behavior (ideation, plans, and attempts) among HIV clinic attendees in sub-Saharan Africa. Additional strengths of this study include the use of psychometrically standardized ascertainment instruments for making the diagnosis and our large sample size.
In conclusion, suicidal behavior is common among HIV-positive patients in our setting, despite HAART, emphasizing the need to enable their early diagnosis and effective treatment in HIV clinics. The introduction of routine self-reported screening for depression and suicidal ideation in HIV clinics may be an important measure in the early identification of PLWHIV at risk for self-harm. Our results also suggest that psychosocial factors are important in predicting suicidal behavior in patients receiving care for HIV. Efforts aimed at prevention of suicidal behavior and consequently completed suicides in PLWHIV will need to pay attention to these psychosocial factors, since they could be modified through targeted interventions designed to improve resilience, interpersonal relationships, social support, and mental health.
Footnotes
Acknowledgments
The authors acknowledge funding support from the University of Ibadan and thank APIN for funding the ART Service where the study was done. The authors also acknowledge the patients and the staff of the clinic for their cooperation. The authors are grateful to Baiba Berzins, MPH, and Leah Welty, PhD, for their comments on early drafts of this manuscript.
Authors’ Note
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research training of Dr Bibilola Oladeji was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW009608.