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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 4  |  Page : 349-354

Study of the severity of depression and quality of life in adults with HIV/Acquired Immunodeficiency Syndrome at antiretroviral therapy center in western Maharashtra


1 Department of Psychiatry, Government Medical College, Miraj, Maharashtra, India
2 Department of Psychiatry, RCSM Government Medical College, Kolhapur, Maharashtra, India
3 Department of Psychiatry, Sri Siddhartha Medical College, Tumkur, Karnataka, India

Date of Submission17-Aug-2022
Date of Decision27-Oct-2022
Date of Acceptance03-Nov-2022
Date of Web Publication30-Jan-2023

Correspondence Address:
Dr. Vishal Ganpati Patil
C/o Arjun Salunkhe, Plot No. 57, Near Amey Residency, Vidhata Colony, Near Swapn Nagari, Vishrambag, Sangli - 416 415, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_138_22

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  Abstract 


Introduction: The universal access to antiretroviral therapy (ART) has caused a significant reduction in morbidity and mortality in HIV-infected individuals. Depression is one of the most prevalent psychiatric diagnoses seen in HIV-positive individuals, which has a significant impact on health-care utilization, adherence to ART, and quality of life (QOL). Hence, this study was planned to study the depression severity and health-related QOL in HIV-positive individuals. Aim: The aim was to study the severity of depression and QOL in adults with HIV/acquired immunodeficiency syndrome (AIDS). Methods: This was a cross-sectional study conducted at the regional ART center of a tertiary care hospital where 90 adult patients with HIV/AIDS in the age group of 18–60 years fulfilling DSM V criteria for depression were interviewed. A semistructured questionnaire was applied to obtain sociodemographic data. Quick Inventory of Depressive Symptomatology and QOL Scale (WHO QOL-HIV BREF) were used to assess the severity of depression and QOL in patients. Results: Of 90 patients, 40% had severe depression and 60% had mild-to-moderate depression. The severity of depression had a significant correlation with duration of HIV illness, duration of depressive symptoms, and socioeconomic status. The low QOL mean score was observed in all domains of QOL questionnaire. There was a significant correlation between the severity of disease and QOL. No correlation was found between CD4 count and QOL or severity of depression. Conclusions: Early diagnosis and treatment of depression in HIV may help improve the QOL of patients. CD4 cell count alone may be inadequate criteria for the prediction of mental health status and QOL.

Keywords: Acquired immunodeficiency syndrome, depression, HIV, quality of life


How to cite this article:
Salunkhe RA, Khot PV, Ainapur K, Patil VG. Study of the severity of depression and quality of life in adults with HIV/Acquired Immunodeficiency Syndrome at antiretroviral therapy center in western Maharashtra. Ann Indian Psychiatry 2022;6:349-54

How to cite this URL:
Salunkhe RA, Khot PV, Ainapur K, Patil VG. Study of the severity of depression and quality of life in adults with HIV/Acquired Immunodeficiency Syndrome at antiretroviral therapy center in western Maharashtra. Ann Indian Psychiatry [serial online] 2022 [cited 2023 Mar 26];6:349-54. Available from: https://www.anip.co.in/text.asp?2022/6/4/349/368779




  Introduction Top


As per the recently released India HIV Estimates 2019 Report, there are an estimated 23.48 lakh (17.98 lakh–30.98 lakh) persons living with HIV (PLHIV), and Maharashtra has estimated to have the highest number of PLHIV (3.96 lakh).[1] Advance in early detection and treatment of HIV have allowed many of the patients to live longer and healthier lives, such that HIV/acquired immunodeficiency syndrome (AIDS) is now viewed as a chronic manageable illness. The average age of HIV-infected people in India has increased and is expected to further increase with expanding antiretroviral therapy (ART) uptake and improved survival associated with that.[2]

With any chronic disease, quality of life (QOL) issues become important. Such issues include the biopsychosocial sequelae of living with HIV AIDS. Various researches show that the significant prevalence of mental disorder in people with HIV with half experiencing depression at some point of time during their course of illness.[3],[4] In addition, it has been documented that depression when left untreated can have harmful effect on immune system functioning.[5] Depression has a serious effect on patient's QOL and has an important impact on course and outcomes of HIV infections through its effect on patient's adherence to medicine regimen.[6] Psychosocial stressors such as stigmatization, loss of support system, fear of dying, adjustment to illness, and different sociocultural factors across geographical areas play role in the development of depression in HIV.[7] It is, therefore, necessary to identify the various factors associated with the severity of depression across cultures.

Although there are various studies available on the topic of mental health in people living with HIV, availability of studies in the Indian context is a very few. Therefore, this study was undertaken to study the factors associated with the severity of depression and QOL in people living with HIV.

Aims and objective

  1. To assess the severity of depression in persons living with HIV
  2. To assess the QOL in PLHIV
  3. To study the factors associated with the severity of depression in PLHIV.



  Methods Top


Study design

This was a hospital-based, cross-sectional, descriptive study.

Study group

It was a cross-sectional study carried out in the ART center of government medical college of western Maharashtra. The Ethics Committee of the institute approved the study, and the participants were recruited after obtaining written informed consent. Ninety adult patients with HIV/AIDS in the age group of 18–60 years fulfilling DSM V[8] criteria for depression were recruited. Patients with serious medical illness, psychotic symptoms, and those who were unable to give consent were excluded from study.

Data collection

Patients were assessed with a semistructured pro forma containing detailed sociodemographic profile, standard scales, and question pertaining to the aim of study.

Study instruments

Quick Inventory of Depressive Symptomatology-SR

It is a self-report measure of the presence and severity of depression based on nine depression symptoms domain that defines a major depressive episode as outlined in DSM V. The Quick Inventory of Depressive Symptomatology (QIDS) consists of 16 items which are rated on 0–3 scale that reflects symptoms' severity. Symptoms are evaluated over the past 7 days. The total score ranged from 0 to 27. Threshold scores correspond to different levels of depression. Internal consistency is high for the QIDS-SR (Cronbach's α = 86). QIDS-SR is a reliable and valid instrument with acceptable psychometric properties to measure depressive symptoms.[9]

Quality of Life Scale (WHO Quality of Life-HIV BREF)

It consists of 31 items. For each item, there is a 5-point Likert scale where 1 indicates low or negative perceptions and 5 or positive perception. These items contain six domains: physical health (four items), psychological well-being (five items), social relationships (four items), environmental health (eight items), level of independence (four items), and spiritual health (four items). Domain scores were scaled in positive directions (higher scores denoting a higher QOL). The main score of item within each domain was used to calculate the domain scores by multiplying by 4 so that the score rated from 4 to 20, with a higher score indicating a better QOL.[10]

Data analysis

The collected data were analyzed with SPSS 20 version for Windows (IBM, Armonk, NY, USA), and two-tailed P value was obtained for all statistical analyses. P < 0.05 was considered statistically significant. Correlations were carried out with the Pearson's rank correlation coefficient and Chi-square test where appropriate.


  Results Top


[Table 1] shows the sociodemographic parameters of the study participants. The mean age of the participants was 31.6 ± 7.5 years. Most of the patients were male (70%), married (76.6%), living in joint families (53.3%), and from rural background (66.6).
Table 1: Sociodemographic indicators

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[Table 2] shows that the majority of the participants had illness for more than 2 years; the mean duration of illness was 2.4 ± 1.0 years. 66.7% of the participants acquired HIV through the sexual mode of transmission. Majority (66.6%) of the participants had no or partial knowledge of HIV. Twenty percent of the participants had not disclosed HIV status to their family members. The average CD4 count of the participants was 257 ± 122.7 cells/ml. Sixty-seven percent of the participants had CD4 count of more than 350 cells/ml. Most of the participants were in stage 3 or stage 4 of the WHO clinical staging. Sixty percent of the participants had no regular adherence to treatment.
Table 2: Illness characteristics of human immunodeficiency virus

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[Table 3] shows the phenomenological characteristics of depression in HIV. The mean duration of depressive feature was 1.31 ± 0.68 years. Only 6 (6.66%) patients had a history of depression. Most of the patients (86.6%) had sadness of the mood lasting for a large part of the day. Ninety percent of patients had developed anhedonia. Majority (63.3%) of the participants had psychomotor retardation. Few patients had mood-congruent psychotic features like the delusion of guilt. 36.6% of patients had a passive death wish. Twenty-three percent of the study participants had suicidal ideation when interviewed. Forty percent of patients had an idea of hopelessness/helplessness/worthlessness. The mean QIDS score for these participants was 14.8 ± 4.2 with range from 0 to 27. Forty percent of patients had severe depression, and 60% of patients had mild-to-moderate depression.
Table 3: Phenomenology of depression in person living with human immunodeficiency virus

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As shown in [Table 4], there was a negative correlation between the severity of depression and duration of HIV (P = 0.007, r = −0.47), duration of depression (P = 0.04, r = −0.36) and income (P = 0.002, r = −0.54). We did not find any relation between CD4 count and severity of depression (P = 0.97, r = 0.007).
Table 4: The Pearson's/Spearman's (r) correlation coefficient of depression with clinical and social variables (n=90)

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As depicted in [Table 5], the low QOL mean score was observed in all domains of QOL questionnaire (WHO QOL–HIV BREF).
Table 5: Distribution of means, standard deviation, and range of raw scores obtained from the quality of life questionnaire (World Health Organization quality of life – human immunodeficiency virus BREF) by domain (n=90)

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[Table 6] depicts the correlation of QOL with the severity of disease and CD4 count of the study participants. There was a significant correlation between the severity of disease and QOL. No correlation was found between CD4 count and QOL.
Table 6: Correlation of quality of life with the severity of disease and CD4 count

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  Discussion Top


Sociodemographic indicators

In previous studies, though females were found more prone to depression, in our study, most of the participants were male.[11] The male preponderance might have been due to the existing social milieu, females do not seek medical care fearing ostracism, gender bias, social stigma, and neglect attached with the disease, which decreases the number of females attending the ART center in rural and semiurban areas.

Mode of transmission

According to the NACO Surveillance Report 2010, sexual contact was the mode of transmission in 89% of patients. In our study, 66.7% of the patients had acquired HIV through the sexual mode of transmission.[12] This variation is likely due to the larger percentage of patients in our study were unwilling to disclose the nature of transmission of HIV (20%).

Disclosure of HIV status

The overall outcome of HIV status disclosure was positive. The majority of patients (60%) reported positive outcomes following disclosure, like kindness, understanding, and acceptance. More importantly, disclosure was not associated with the breakage of marriage. The positive outcome can be attributed to the family-oriented Indian society and in small measures to the ignorance of caregivers about the full implication of the epidemic. This is in keeping with the finding of previous studies.[13]

Twenty percent of the participants had not disclosed their positive HIV status. Fear of being a burden to family members, fear of being identified and rebelled as HIV-positive, and stigma surrounding HIV may be some of factors responsible for keeping a positive diagnosis a secret.

CD4 count, WHO clinical staging, and treatment

Sixty-seven percent of the patients had CD 4 count of more than 350 cells/ml. The entire sample was in either stage 3 or 4. Some antiretroviral medications have been implicated in the development of neuropsychiatry syndromes, including depressive disorder.[14] However, longitudinal follow-up studies on the relationship between ART and depressive disorder found that ART appears to decrease the depressive disorder overall.[15]

Depression

The mean duration of depressive features was 1.31 ± 0.68 years. A history of depressive disorder is one of the risk factors for the development of depressive disorder after diagnosis of HIV. However, most of our patients had no history of depressive episode. Depressive episode after diagnosis of HIV infection could be related to psychosocial stress of receiving diagnosis of HIV infection.

Phenomenology of depression

The pattern of mood features in our study was in keeping with the finding of the previous study.[16] Anhedonia was common in our patient. When asked, most of them said that they had interest in only one or two of their previously pursued activities. Most of the females had lost interest in all the activities. They lost their interest in their children or spouse, who once were the source of joy. In co-occurrence with previous studies, most of our patients had psychomotor retardation.[16] They had a paucity of spontaneous movements. They often had a reduced flow and amplitude of speech and increased latency of responses. Similar to previous studies, symptoms of cognitive disturbances revealed difficulty in concentration, easy distractibility, and subjective reporting of decrease in sharpness of thinking by patients.[17] Females had more impairment in household work and few males had to change their job due to their inability to concentrate. Suicidal thoughts were common findings in our study matching the findings of previous studies.[18] Suicidality was primarily passive, described as a thought that life was not worth living rather than having active thoughts of self-harm. This high frequency of suicidal thoughts, in general, with a low frequency of specifically active suicidal ideation, is consistent with the prior studies.[16] The overall frequency of suicidal ideation in our study is less compared to previous studies.[19] It might be because we did not include substance abuse/dependence patients in our study. All the suicide attempts were made during the 1st week after the revelation of seropositive status. This finding is attributable to the acute psychological distress suffered by the patients during this period. At the time of diagnosis, patients were faced with the thoughts of loss of employment, economic instability, rejection by family and friends, and fear of stigma. However, with the passage of time, the patient had a chance to cope with their predicament and adapt to the situation. Further social support provided by their kin was a major factor that played a role in alleviating acute mental pain and concurrence risk of attempting suicide. Most of the patients had insomnia, weight loss, loss of appetite, loss of energy, and unusual fatigue. Some of these features might have been due to HIV also.

Severity of depression

The mean QIDS score of the participants was 14.8 ± 4.2. The mean QIDS score in previous study was 16.[16] The reason for lower score could be the exclusion of patients of substance abuse/dependence. Most of the patients (66.66%) had moderate-to-severe depression. The negative correlation of duration of illness (HIV) and depression (P = 0.007, r = −0.47) can be explained by psychological stress in early months after diagnosis of HIV. We found a significant negative correlation between known duration of depression and severity of depression (P = 0.04 r = −0.36). This is due to increasing coping strategies over period of time. With the passage of time, the patient became increasingly aware that HIV is a treatable disease. This finding is in conformity with the other studies.[20]

No correlation was found between CD4 count and severity of depressive symptoms (P = 0.97, r = 0.007). Similar findings were observed in one study in South African population using the Beck Depression Inventory.[21] However, some studies observed an increasing level of depression in patients with a decrease in CD 4 count, but due to a cross-sectional design, this study was not able to conclude whether a low CD4 count is a cause or a consequence of the depressive disorder.[22] In our study, those who had a low socioeconomic status were more severely depressed (P = 0.002, r = −0.54). This finding agrees with a previous study showing patients who lose their jobs due to illness and have low income are significantly more likely to be depressed.[23] Most of the patients were not taking treatment for depression for fear of further stigmatization.

Quality of life

The lower QOL mean score was observed in all domains, similar to findings in the previous study.[24] Low score in "physical domain" (pain and discomfort, energy and fatigue, sleep and rest; and symptoms related to HIV) reflects the impact of HIV/AIDS on the physical health of the patient. This highlights the need for access to antiretroviral drugs for all symptomatic patients because the lower the morbidity in an individual better is his physical domain score.

The "psychological domains" describe the five facets: positive feelings, concentration, self-esteem, body image, and negative feelings. Participants in this study obtained low score in this domain. They experienced a high rate of negative feelings toward both their present situation and their future. They had low self-esteem and difficulty in concentration on their routine work due to fatigue caused by HIV/AIDS and depression similar to finding in previous studies.[25]

The level of "independence domain" describes four facets: mobility, activity of daily living, dependence on medication, and treatment and work capacity. Participants suffered from the hampered level of independence, because their illness restricted their mobility. Some patients were unable to pursue their occupations and earn their livelihood. Although our study revealed an overall positive and supportive family environment, the patients scored low on the environmental domains. This is attributable to the lack of financial resources as most patients were from lower socioeconomic status.

Low score on "spirituality, religion, and personal belief domains" was because patients felt guilty that they were at fault for their current HIV status. They had a fear of impending death and shakiness of their personal belief following understanding of their predicament, possibly exacerbated by their depressive mood in this study.

We found a significant correlation of QOL with income and socioeconomic status, similar to findings in previous studies.[26] Participants with low socioeconomic status have decreased access to medical services and poor nutritional status which can affect QOL. All domains of QOL scored low in patients with major depressive disorder, and QOL decreased as the severity of depression increased, which is in accord with previous studies.[24],[25] The adverse physical and sociooccupational consequences of their illness lead to a deterioration of QOL. This, in turn, increased the severity of depression. Depression interferes with good self-care practices including treatment-seeking behavior and thereby negatively impact QOL in person of HIV/AIDS thus forming a vicious cycle.

We did not find any correlation between CD4 count and QOL, which was in keeping with the findings of previous studies though some studies found only weak correlation between them.[27],[28] Due to variable findings, we can conclude that CD4 count and QOL cannot be proxies of each other and that the CD4 cell count alone may be inadequate criteria for the prediction of QOL.


  Conclusions Top


Majority (60%) of the participants had mild-to-moderate depression on the QIDS Scale, while 40% of the participants had severe depression. The severity of depression was significantly correlated with duration of illness (HIV), duration of depressive symptoms, and socioeconomic status. On QOL Scale, all patients had a poor score on all domains. Low QOL was associated with the severity of depression and low socioeconomic status. No significant correlation was found between CD 4 count and severity of depression or QOL.

Limitations

This was a single-center, cross-sectional study done in the government hospital in a semiurban area on a limited sample size. The sample may not be a representative of the entire population. The study was restricted to the health-related QOL from the patient's perspective. The other aspects of QOL and objective evaluation were not considered for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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