Original Article
A comparison of clinical features among patients suffering
from depression in HIV positive and HIV negative cases
Dr.Harish Arora,
Prof & Head, Dept. of Psychiatry,
G.G.S.Medical College, Faridkot.
Dr. Rajdeep kaur,
Medical officer,
Civil Hospital, Gurdaspur.
Abstract- Depression is common in patients with HIV/AIDS, and its
identification and treatment are critically important in disease management. HIV
positive individuals have a estimated prevalence rate of depression about 22% 45% compared with 15% of general population. This study compared the clinical
features of major depressive disorder between HIV-Positive and HIV-negative
patients with a view to intervention strategies. Method: A comparative,
descriptive, cross-sectional study was carried out on 50 HIV-Positive depressed
patients and 50 HIV-negative depressed patients in ICTC centre of Civil hospital,
Gurdaspur. They were compared along the parameters of clinical features of
depression and physical examination. Results: Compared to HIV-Negative
patients, HIV positive patients were more likely to have a medical illness and
taking medication before onset of depression, symptomatically compared to
HIV-Negative patients. HIV-Positive patients had poorer sleep, felt more easily
tired, more appetite changes, more suicidal ideation. Conclusion: These
findings show that the clinical and associated features of depression differ
between HIV-Positive and HIV-Negative patients, thus requiring different
management approaches and further studies related to HIV-related depression.
1
Key words: Depression, HIV/AIDS.
INTRODUCTION
HIV/AIDS is a global health problem. In the last two decades it has
claimed nearly 30 million lives1. About 40 million people are now
living with HIV/AIDS. HIV infection is one such condition where the
disease itself may cause many symptoms resembling those of
depression. On the other hand, several psychiatric conditions
including depression may predispose individuals to acquire HIV
infection as a consequence of their influence on behaviour2,3.
Prevalence of depression among HIV infected population is shown to
be varying from 0 - 47% in different studies. Despite this, a metaanalysis of ten studies comparing HIV-positive and at risk HIV negative patients demonstrated a twofold increase in the prevalence
of major depression in patients infected with HIV4.
This variation is wide enough to raise questions on the methods and
criteria used in the different studies. There are conflicting results
regarding the influence of stage of HIV infection on depression and
anxiety. One study showed poor correlation with severity of apathy
and cognitive performance with incidence of depression5. Another
study conducted at a specialty HIV clinic at a tertiary health care
centre in South India reported 40% of seropositive individuals
suffering from syndromal depression. Anxiety severe enough to
fulfill the ICD-10 criteria for generalized anxiety disorder has been
found in 90% of the HIV infected individuals with depressive
symptoms.
Suicidal tendency among HIV patients was highest during the first
week after the revelation of the seropositive status and all of those
who attempted suicide had past history of psychiatric illness6,7.
Majority of studies done in India have reported higher rates of
depression among women compared to men which is implicated to
higher caregiver burden, more social stigma and poor healthcare8.
2
Greater severity of depression, on the other hand, has been found to
be associated with greater frequency of injection risk behavior among
depressed injection drug abusers making them more vulnerable to
HIV infection2,3.
This study therefore aimed to investigate and compare clinical
features of depression in HIV-positive patients and HIV-negative
patients with a view to delineate HIV-related depression as a clear
clinical entity with treatment implications. For the purposes of this
study, a depressed patient was defined as a patient who, at the time
of the study, had signs and symptoms of a major depressive episode
as defined in the DSM-IV-TR9.
Method
This was a cross sectional, descriptive, comparative study conducted
at the Civil hospital, Gurdaspur.
All the study patients met criteria for DSM-IV-TR major depressive
disorder, were above 18 years and gave written consent. Those with
other active physical illnesses and alcohol abuse were excluded from
the study. An HIV test was done after pre-test counseling.
Psychiatrist was attached to the ICTC centre where the patients were
accessing care diagnosed the depression.
The diagnosis of depression was done with DSM-IV criteria, a
standardized sociodemographic questionnaire was administered, the
patients were physically examined and a blood test was done for
diagnosis of HIV after pretest and then later post test counseling was
done by counselors of ICTC centre. Other blood tests included CD4
levels. Univariate analysis was used to describe the characteristics of
the respondents and the two groups were compared using univariate
analysis. Variables that had significant differences at univariate
analysis between the two groups were then included in a
multivariate logistic regression model to determine independent
associations. Total 100 patients were included in the study, 50 HIV
positive patients and 50 HIV negative patients.
3
Results
Total 100 patients were included in the study, out of which
50 patients were HIV-positive and 50 patients were HIVnegative. The mean age of patients was 30.5 years and 58
(58%) of patients were aged between 18-30 years. The two
groups (HIV-positive and HIV-negative) were then
compared.
Table I: Sociodemographic characteristics of the study patients
Characterstic
HIV
Positive=50
HIV
Negative=50
X2
OR( 95%CL)
P-Value
Gender
Male
Female
35
15
40
10
1.333
0.583(0.233-1.463)
0.248
not
significant
Age group
18-30
30-60
18
32
40
10
19.869
0.141(0.057-0.347)
<0.001
highly
significant
Mean age
18-60
33
28
Marital status
Married
Never married
Widowed
Separated
26
12
12
0
20
27
3
0
11.952
0.003
significant
6
35
9
8
32
10
0.473
0.79
not
significant
28
12
10
30
15
5
2.069
0.355
not
significant
10
28
10
20
10
12
15.641
0.001
significant
Education
Illiterate
Primary
Secondary&
graduation
Religion
Hindu
Sikh
Christian&
muslim
Employment
Employed
Unemployed
Farmer
4
Student
2
8
40 patients( 80%) were in age group 18-30 in HIV-negative group and
18 patients( 36%) in HIV-positive group. Whereas in 30-60 years age
group had 10 patients( 20%) in HIV-negative group and 32 patients(
64% ) in HIV-positive group. This age group was compared and this
difference was found highly significant( P<0.001 ).
Regarding marital status, HIV-positive people were more married
26(52%) and widowed 12(24%). In HIV-negative group, people were
more unmarried 27(54%). P value calculated is 0.003 which is
significant.
More unemployed people 28( 56%) were found in HIV positive group
compared to 10( 20%) people in HIV negative group. On further
analysis of employment data, P value found is 0.001 which is
significant.
There were no statistically significant differences on the other
sociodemographic parameters. (Table I)
Table II: General characteristics of the study patients
Characterstic
HIV
Positive
HIV
Negative
X2
26
14
12
36
14
28
4.244
29
18
4.857
Taking medicine before
depressive episode
22
5
14.663
Medical illness before
depressive disorder
28
3
29.219
19.939(5.46872.71)
Lost a sexual partner
3
1
1.042
3.128(0.314-
Age of onset
18-30
>30 years
Family member with
Mental illness
Currently first episode
10.667
5
OR((95%CL)
0.248(0.1050.584)
2.455(1.0975.494)
7.071(2.40220.814)
P value
0.039
Significant
0.001
Significant
0.028
Significant
<0.001
Highly
significant
<0.001
Highly
significant
0.307
before admission
31.14)
Not
significant
Compared to HIV positive group, HIV negative group patients had
earlier onset of depression in age group of 18-30 years i.e 36(72%)
compared to 26(52%) in HIV positive group.This difference is found
to be significant (P value 0.039). HIV negative people had more
family members with mental illness compared with other group(
28/56% and 12/24% respectively). This difference is significant ( P
value- 0.001).
29(58%) of HIV positive patients had first episode of depression
compared to 18(36%) of HIV negative group patients. Statistically this
difference is significant having P value 0.028. 22(44%) of HIV patients
were taking some form of medicines before the onset of depression as
compared to 3(6%) of patients in HIV negative group. This difference
is highly significant having P value <0.001.
HIV positive group also had more medical illness compared to HIV
negative group ( P value <0.001); highly significant. There were no
statistically significant differences on the other sociodemographic
parameters. (Table II)
Table III: Depressive clinical features observed in patients
Clinical
Feature
Depressed mood
HIV
Positive
46
HIV
Negative
45
X2
OR(95%CL)
P Value
0.727
1.278(0.322-5.066)
Loss of interest in
work
45
44
0.564
0.716(0.229-2.238)
Appetite changes
41
38
0.461
1.439(0.545-3.797)
Sleep problems
46
39
0.049
Slowed down
41
40
0.799
3.244(0.95611.001)
1.13990.4193.097)
Feeling tired
37
42
0.22
0.727
Not
significant
0.564
Not
significant
0.461
Not
significant
0.049
Significant
0.799
Not
significant
0.22
6
0.542(0.20-1.452)
Feeling worthless
25
32
0.157
0.563(0.253-1.252)
Difficulty
concentrating
41
39
0.617
1.285(0.480-3.437)
Suicidal ideation
30
18
0.016
2.667(1.188-5.985)
Not
significant
0.157
Not
significant
0.617
Not
significant
0.016
Significant
Among clinical features observed in depressed patients in both
groups, sleep problems (p value-0.049) and suicidal ideation (p value0.016) was found to be statistically significant. Other features were
not found significant.
Discussion
Findings from this study show that there are differences in the
clinical features between HIV-positive and HIV- negative depressed
patients. This study was able to demonstrate that HIV-positive
patients were less likely to have a family member with a mental
illness and have later onset of depressive illness. Symptomatically,
compared to HIV-negative patients, HIV-positive patients had poorer
sleep ,felt more easily tired, had appetite changes and more suicidal
ideation. The study limitations include the fact that it was conducted
in hospital settings and may thus be subject to bias. Recall bias as far
as history of previous and family history of mental illness may also
affect the results. The sample size is relatively small compared to
other studies that generally had larger sample size. Studies with
larger sample sizes need to be conducted.
a) Socio demographic characteristics
Compared to HIV-positive patients, HIV-negative patients were
younger, had an earlier onset of depression, were more likely to be
employed. The socio-demographic findings of older age and later
onset of depression among the HIV-positive patients suggest HIV as
7
being an etiological factor in their depression.10 The differences seen
clinically may also be due to the fact that the older HIV-positive
patients had gone through numerous life events such as divorce and
loss of partners to HIV/AIDS. Depression associated with HIV may
therefore be acquired and secondary to HIV/AIDS and different
from the primary depression in HIV-negative patients. Indeed
secondary affective disorders in HIV/AIDS have been reported in
other studies11. There was a high rate of unemployment among the
HIV-positive patients. Unemployment could possibly be a
consequence of HIV disease severity. Unemployment has also been
known to compound depression12.
b) General patient characteristics
The HIV-positive patients were less likely to have a family member
with a mental illness, were more likely to have had a medical illness
before onset of depressive symptoms and were more likely to have
been taking medicines before onset of depressive symptoms.
This particular finding was unique to this study. It may mean that
HIV-positive patients were attempting to self medicate using nonprescribed over the counter medications for the symptoms that had
not been identified by other practitioners before getting psychiatric
help. Depressive symptoms in HIV infection have been reported to
manifest up to 1.5 years before onset of AIDS13,14. Medical illness as
the probable cause of depression was ruled out by carrying out a
complete physical examination and blood tests. Patients with an
active medical condition other than HIV/AIDS, were excluded from
the study. It is therefore more likely that these patients were unlikely
to be receiving medications for a diagnosable medical illness but
rather, they were more likely to be self-medicating for somatization.
It is therefore possible that these patients were suffering numerous
somatization symptoms as indicators of psychological distress before
onset of their major depression.
c) Clinical characteristics
8
HIV-positive depressed patients differed from their HIV-negative
counterparts for the parameters of sleep and suicidal ideation. The
findings of sleep were in keeping with previous studies15,16. However
unlike these studies15,16 our HIV-positive patients had fewer appetite
disturbances. The explanation for this finding is not clear. Previous
research has documented an increase in suicidal ideation and suicide
attempts in HIV-positive patients17,18. The findings of our study are
also the same.
Conclusion
This study showed that HIV-related depression is clinically different
from the depression found in HIV-negative patients. It appears to be
acquired and therefore a secondary depressive illness as opposed to
the genetically driven primary affective depressive disorder of HIVnegative patients. This requires further study. The HIV-related
depression was characterized by negative family history of mental
illness, use of medication for treating an illness other than
depression, older age of the patients, older age of onset of the
depression and cognitive impairment. Compared to HIV-negative
patients, HIV-positive patients more sleep and more suicidal
ideation. These findings call for routine screening for depressive
illnesses in all HIV infected individuals especially in late onset
depressive illness and in people suffering from HIV/AIDS as well as
for effective treatment of the depression in HIV/AIDS cases.
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