A Comparison of Clinical Features among Patients Suffering from Depression in HIV Positive and HIV Negative Cases

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1 Original Article A Comparison of Clinical Features among Patients Suffering from Depression in HIV Positive and HIV Negative Cases Rajdeep Kaur, Ramandeep Kaur Civil Hospital, Gurdaspur, Punjab Abstract Background: 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 HIVrelated depression. Key words: Depression, HIV/AIDS. Introduction HIV/AIDS is a global health problem. In the last two decades it has claimed nearly 30 million lives 1. 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 behaviour 2,3. 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 HIV 4. 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 depression 5. 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 160

2 APRIL 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 highest during the first week after the revelation of the seropositive status and all of those who attempted suicide had past history of psychiatric illness 6,7. Majority of studies done in India have reported higher rates of depression among women compared to men which is implicated to cause higher caregiver burden, more social stigma and poor healthcare 8. 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 infection 2,3. This study therefore aimed to investigate and compare clinical features of depression in HIVpositive 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-TR 9. 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. Results Total 100 patients were included in the study, out of which 50 patients were HIV-positive and 50 patients were HIV-negative. The mean age of patients was 30.5 years and 58 (58%) of patients were aged between years. The two groups (HIV-positive and HIV-negative) were then compared. 40 patients (80%) were in age group in HIV-negative group and 18 patients (36%) in HIVpositive group. Whereas in 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 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 which is significant. Ther e were no statistically significant differences on the other sociodemographic parameters. (Table 1) Compared to HIV positive group, HIV negative group patients had earlier onset of depression in age group of 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 ). 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 (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 < HIV positive group also had more medical 161

3 Table-1: Sociodemographic characteristics of the study patients Characterstic HIV HIV Positive=50 Negative=50 X2 OR (95% CL) p-value Gender Male ( ) not Female significant Age group ( ) < 0.001highly significant Mean age Marital status Married Never married significant Widowed 12 3 Separated 0 0 Education Illiterate Primary not significant Secondary & graduation 9 10 Religion Hindu Sikh not significant Christian & muslim 10 5 Employment Employed Unemployed significant Farmer Student Table-2: General characteristics of the study patients Characterstic HIV HIV X2 OR ((95%CL) p value Positive Negative Age of onset >30 years Significant Family member with Mental illness ( ) Significant Currently first episode ( ) Significant Taking medicine before depressive episode < ( ) Highly significant Medical illness before depressive disorder < ( ) Highly significant Lost a sexual partner before admission ( ) Not significant illness compared to HIV negative group ( P value <0.001); highly significant. There wer e no statistically significant differences on the other sociodemographic parameters. (Table 2) Among clinical features observed in depressed patients in both groups, sleep problems (p value ) and suicidal ideation (p value-0.016) was found to be statistically significant. Other features were not found significant. Discussion Findings from this study show that there are 162

4 APRIL 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 Table-3: Depressive clinical features observed in patients Clinical Feature HIV Positive HIV Negative X2 OR (95%CL) p- value Depressed mood ( ) Not significant Loss of interest in work ( ) Not significant Appetite changes ( ) Not significant Sleep problems ( ) Significant Slowed down ( ) Not significant Feeling tired ( ) 0.22 Not significant Feeling worthless ( ) Not significant Difficulty concentrating ( ) Not significant Suicidal ideation ( ) Significant differences in the clinical features between HIVpositive 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, HIVnegative 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 being an etiological factor in their depression. 10 The differences seen clinically may also be due to the fact that the older HIVpositive 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 HIVnegative patients. Indeed secondary affective disorders in HIV/AIDS have been reported in other studies 11. 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 depression 12. 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 non-prescribed 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 AIDS 13,14. 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 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 studies 15,16. However unlike these studies 15,16 our HIV-positive patients had fewer appetite disturbances. The explanation for this finding is not clear. Previous research has 163

5 documented an increase in suicidal ideation and suicide attempts in HIV-positive patients. 17,18 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 primar y affective depressive disorder of HIV-negative 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 have more sleep problems 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. References 1. WHO and UNAIDS: Global initiative to provide antiretroviral therapy to 3 million people with HIV/AIDS in developing countries by the end of 2005, World Health Organization, Geneva Michael DS, David AS, Bbra SH, et al. Depression severity and drug injection HIV risk behavior.am J Psychiatry 2003; 160 : Woody GE, Metzger D, Navaline H, et al. Psychiatric symptoms, risky behavior and HIV infection. NIDARes Monogr 1997; 172 : Ciesla JA, Roberts JE. Meta-analysis of relationship between HIV infection and risk for depressive disorders. Am J Psychiatry 2001; 158 : Castellon SA,Hinkin CH, Wood S, Yarema KT. Apathy, depression and cognitive performance in HIV-1 infection. J Neuropsychiatry Clin Neurosci 1998; 10 : Mazruk PM, Tardiff K, Leon AC, et al. HIV seroprevalence among suicide victims in New York City, Am J Psychiatry 1997; 154 : Dannenberg AL, McNeil JG, Brundage JF, Brookmeyer R.Suicide and HIV infection: mortality follow-up of 4147 HIV sero-positive military service applicants. JAMA ; 276 : Chandra PS, Desai G, Ranjan S. HIV and psychiatric disorders. Indian J Med Res 2005; 121 : Kaplan and Saddock s Synopsis of Psychiatry, Behavioral Sciences /Clinical Psychiatry, 9TH Edition, Lippincott Williams & Wilkins Evans DI, Ten Have TR, Douglas SD, et al. Association of Depression with Viral Load, CD8 T Lymphocytes, and Natural Killer Cells in Women With HIV Infection. Am J Psychiatry 2000; 159 : Folstein MF, Folstein SE, Mc Hugh P. Mini Mental State A practical method for grading the cognitive function state of patients for the clinician. J Psychiatr Residence 1975; 12 : Rosack J. Depression Most Costly Illness for Employers, Psychiatric News 2003; 38 (14). 13. Lyketsos CG, Hoover DR, Guccione M et al. Changes in depressive symptoms as AIDS develops. The Multicenter AIDS Cohort Study. Am J Psychiatry 1996; 153 : Halman M: Management of depression and related neuropsychiatric symptoms associated with HIV/AIDS and antiretroviral therapy: Can J Infect Dis 2001; 12 (Supp C): 20C-30C. 15. Musisi S, Nakasujja N, Zziwa S. Depression among HIV/TB cormobidity in Mulago hospital. Proceedings of the second annual faculty of medicine scientific conference; Munyonyo, Uganda, Sept 7th - 9th Norton J. The Neuropsychiatric Symptoms of AIDS. Am J Psychiatry 2000; 157 : Stern RA, Perkins DO, Evans DL. Neuropsychiatric Manifestations of HIV-1 Infection and AIDS, Neuropsychopharmacology. Bloom FE, Kupfer DJ (Eds). New York: Raven Press Limited, Ruiz P. Living and Dying with HIV/AIDS: A Psychosocial Perspective. Am J Psychiatry 2000; 157 :