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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 32  |  Issue : 2  |  Page : 149-153

Depression and coping mechanism among HIV/AIDS patients under anti-retroviral therapy


Department of Psychology, A.M.U., Aligarh, Uttar Pradesh, India

Date of Web Publication25-Apr-2016

Correspondence Address:
Dr. Salma Kaneez
Department of Psychology, A.M.U., Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.181098

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  Abstract 

Background: HIV infection owing to its chronic course and the associated stigma often results in emotional reactions of a serious nature among the people infected with the illness. Depression is the most common psychiatric syndrome in HIV patients found by various studies. Prevalence rate of depression reported in India among HIV sero-positive individuals is as high as 47%. Symptoms of depression may lead to nonadherence to anti-retroviral therapy (ART) and consequent poorer health. Unfortunately, more than half of the HIV-positive population that suffer from depression have not received official diagnosis of their depression. Objective: The aim of this study was to examine the level of depression and relationship between depression and coping styles among HIV-infected people. Sample: About 30 HIV/AIDS patients receiving ART were assessed for depression and coping strategies they used to deal with the illness. Measures: Beck Depression II inventory and Brief Cope Scale were used for data collection. Results and Conclusion: Findings indicate severe to extreme level of depression among people receiving medical treatment. Although women reported slightly higher level of depression than men, no significant gender difference was observed. Women preferred religion, ventilation, and support coping more than men. A significant positive correlation was observed between depression and avoidant coping (r = 0.505, P< 0.001). Results underline the need to incorporate mental health services as an integral part of HIV/AIDS routine health care.

Keywords: Anti-retroviral therapy, coping strategies, depression, HIV/AIDS, stigma


How to cite this article:
Kaneez S. Depression and coping mechanism among HIV/AIDS patients under anti-retroviral therapy. Indian J Soc Psychiatry 2016;32:149-53

How to cite this URL:
Kaneez S. Depression and coping mechanism among HIV/AIDS patients under anti-retroviral therapy. Indian J Soc Psychiatry [serial online] 2016 [cited 2019 Dec 9];32:149-53. Available from: http://www.indjsp.org/text.asp?2016/32/2/149/181098


  Introduction Top


Despite the promising developments in medical science in recent years, the global AIDS epidemic continues to grow. The success of Anti-retroviral Therapy (ART) has markedly reduced AIDS-related mortality rates and has increased survival for the victims. Yet HIV/AIDS pandemic remains a significant problem for individuals, communities, and even nations, especially in low- and middle-income countries (LMICs). Over 34 million people were living with HIV across the globe, and 68% of all those infected with HIV globally reside in LMIC.[1] In addition, the HIV epidemic in LMIC has had a major impact on their social and economic development. According to official HIV Estimations, the total number of people living with HIV/AIDS (PLWHA) in India is estimated at around 20.9 lakh.[2] Although the prevalence rate is low, people in the productive age of 15–49 years account for about 86% of all infections. Moreover, it has spread to general population and to the rural areas including women and children.[2] Given the poor patient access to health care and deficient health infrastructure, AIDS epidemic poses an insurmountable health challenge for India.

Being a chronic and life-threatening disease, AIDS/HIV is stressful to manage. The person inflicted with the HIV infection has to face medical, psychological, and socio-economic issues specific to the illness. All these factors may often lead to various psychiatric conditions such as anxiety and depression, which force to adapt maladaptive coping style.[3] Advances in the treatment and care of HIV/AIDS have improved the health outlook for PLWHA.[1] The depressive symptoms among HIV patients are still highly common. The prevalence of depression among HIV-infected people was found up to the level as high as 47% by different studies.[4] In a developing country such as India, factors such as low economic status, poor educational background, greater stigma, and inadequate social support have a crucial role in the development of depression during the course of the illness.[5] Higher depressive symptoms were commonly found among PLWHA receiving ART by important studies done in Indian population.[6],[7] Most of the HIV-related depressed patients were often undiagnosed and hence untreated.[8],[9]

The symptoms of depression that do not meet diagnostic criteria can also be distressing and can affect health behavior. The medical condition of HIV infection, its associated opportunistic infections, and side effects of ART can mimic symptoms of depression (i.e., fatigue, concentration problems, somatic symptoms, decreased appetite/weight loss.[10] From a cognitive behavioral perspective,[11] these physical symptoms can become part of a continued depression. Patients can develop negative cognition about the side effects and consequently may be engaged in avoidance behavior. Among PLWHA, depression increases the likelihood of HIV transmission,[12] associated with poor adherence to ART and decreased quality of life (QOL),[13],[14] and may independently increase HIV progression.[15] How an individual cope with the illness is an important factor that can affect the patient's health outcome. Coping refers to “the cognitive and behavioral effort made by a person to alter or manage the problems caused by specific stressful situation.”[16] Coping responses are the actions that an individual employ to manage stress events.[17] It includes active coping (i.e., facing the problem directly/taking an active approach in dealing with the problem), avoidant coping (i.e., attempting to ignore the problem), and support coping (i.e., seeking help from others in addressing the problem). Other studies suggested that problem-focused active coping was strongly associated with the patients' improved QOL and maladaptive coping such as emotion-focused and avoidance were found related with the reduced QOL.[18],[19]

In other words, depression can represent as an enduring clinical syndrome that affects client health status, compliance to ART, and can also alter their QOL. Understanding of how individuals cope with HIV disease is, therefore, essential to the development of effective interventions that can help mitigate depression and improve the QOL of the clients.

Objective

The main objective of the study was to examine the level of depression and coping pattern among HIV/AIDS patients receiving ART treatment and also to find out the relation between depression and their coping styles.


  Methods Top


Sample

The sample consisted of 30 (male = 18; female = 12) HIV/AIDS patients. The sample was collected by the researcher with the help of the staff available in the ART unit. The purposive sampling was chosen to ascertain the extent of depression among the patients and how they deal with their psychological condition. Participants were selected from the ART Unit, Department of Medicine, Jawaharlal Nehru Medical College Hospital, A.M.U., Aligarh. On the basis of the bibliographical information and data available in the ART Unit, age bracket, average monthly income, and rural domicile of the enrolled patients were determined for our sample. Most of the PLWHA were usually following the fixed dose regime of free tenofovir+ lamivudine+ efavirenz medication.

Inclusion/exclusion criteria

Patient receiving ART at least for the last 3 months, belonging to rural, low-income background, between the age group of 22 and 38 years were included in the sample. Pre-ART patients those receiving treatment for <3 months belonging to urban areas were not included in the sample.

Tools

(a) Beck's Depression Inventory (BDI-II) developed by Beck et al.[20] was used to measure patient's current level of depression. BDI have been frequently used for the screening of depression in the HIV patients. It is a 21-item scale with four response categories (0–3). Total scores ranged between 0 and 63. Cronbach alpha of the scale was found to be 0.86. Depression was divided into four categories - mild mood disturbances (11–16), mild depression (17–20), moderate depression (21–30), severe depression (31–40), and extreme depression (>40).

(b) Brief Cope Scale developed by Carver [21] was used to measure coping strategies. Brief Cope generated three global constructs of coping; active, avoidant, and support.[17] Only 12 items of Brief Cope Scale, taking action and positive reframing of active coping, instrumental and emotional support of support coping and behavioral disengagement, religion and ventilation of avoidance coping, were used in the study. It has four response categories, ranging from 1 = not doing this at all to 4 = doing a lot.

Apart from the aforesaid questionnaire, demographic information schedule was also provided to the respondent to get information regarding age, sex, religion, education, socio-economic background, and available support.

Procedure

After seeking permission from the medical superintendent, informed consent was obtained from the participants and questionnaires were administered. Adequate rapport was established with the help of the counselor providing adherence counseling to gather required information. Confidentiality of the data was ensured. Initially, 40 depressed patients were identified with the help of BDI. In the present study, only 30 patients having severe to higher level of depression were formed our sample. The study was also approved by the Ethical Committee of the Medical College.

Statistical analysis

Collated data were analyzed for descriptive statistics. Comparisons between groups were done using t-test and correlation co-efficient. SPSS version-17 (Department of Psychology, AMU, Aligarh) available in the research library was employed for data processing.


  Results Top


Background characteristics of study population

The information about participants as compiled in [Table 1] indicates that they were between the ages of 22 and 38 years with the mean age of 32.77 years. Of the 30 HIV/AIDS patients, 18 (60%) were male and 12 (40%) were female. They were from the rural background. Majority of them, 83.33% (n = 25) were married, 6.67% (n = 2) were unmarried, and rest 10.0% (n = 3) were widowed. More than half, 53.3% (n = 16) were illiterate and remaining 46.7% (n = 14) had primary level education.
Table 1: The demographic characteristics of the population

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Level of depression

Data presented in [Table 1] also revealed that the level of depression among HIV/AIDS patients was severe to extreme. Out of 18 sero-positive males, 27.80% (n = 5) had severe and 72.20% (n = 13) had an extreme level of depression. Whereas of the 12 females, 8.30% (n = 1) manifested severe and 91.70% (n = 11) had an extreme level of depression. It is evident from [Table 2] that depression among women was more severe (mean = 46.58) than their counterparts (mean = 44.50), although no significant gender difference was found.
Table 2: The mean, standard deviation, and t-value of male and female participants on study variable

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Coping mechanism/strategies used

Results shown in [Table 2] revealed that PLWHA significantly differed in case of two factors of avoidant coping: Religion t = 3.61, P < 0.05 and Ventilation t = 2.36, P < 0.01. The mean score shows that women used religion (mean = 4.57) and ventilation (mean = 5.25) more in comparison to men who had a mean score of 1.67 and 4.50.

Moreover, significant difference between male and female participants was also observed with the use of social support (t = 2.67, P ≤ 0.05) as a coping mechanism. The subjects sought support either for instrumental or emotional reasons, but relatively women looked for more emotional support (mean = 5.75) from family and counselors to manage the illness than men (mean = 4.17). Results further showed that there was no significant gender difference between respondents in the use of other coping strategies such as taking action, positive reappraisal, and behavioral disengagement.

Association between depression and coping strategies

The present study found that depression had a positive and significant association with avoidant coping [r = 0.51, P < 0.01, [Table 3], but insignificant and negative relation (r = −0.17) with active and positive relation (r = 0.12) with support coping.
Table 3: The correlation between depression and coping styles (active, avoidant, and support coping)

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  Discussion Top


Depression was a frequent consequence of trying to cope with the chronic illness such as HIV/AIDS. There was an extreme level of depression among the majority of study population. Poor financial background and low literacy level made PLWHA prone to depression. HIV/AIDS was not only responsible for individual morbidity and mortality, but also for familial and social burden by itself. Illiteracy and financial problems multiplied their woes while fighting with the illness. It seems that the prevailing cultural factors turn coping with such a psychological morbidity more difficult for the participants. The results confirmed the findings observed in Indian studies. As reported by Chandra et al.,[22] majority of studies done in India has revealed higher rates of depression among women compared to men. This reflected higher caregivers' burden, more social stigma, and poor health-seeking trends in case of Indian women. Being mother and belonging to economically poor classes, subjects had lots of worries and concerns about their future. The PLWHA felt helpless and released their pent-up feelings through crying and turning toward religion. Relationship with God helped them to provide support and strength to deal with the consequences of a stigmatized and fatal disease. A positive and significant relation between depression and avoidant coping reflected that higher the level of depression, greater the degree of engagement in avoidant coping and vice versa. Due to limited resources and poor health-seeking behavior (limited understanding of the nature of disease), the subjects had little scope for active coping and as a result preferred avoidant coping.

Limitations of the study

The study has certain limitations. The research was undertaken in special population (i.e., HIV-positive people). A parallel control group was not considered. Hence, its results with regard to the prevalence of depression rate cannot be compared with the studies carried out in general population. The relatively small sample size might have hampered generalizations. The self-reporting measures have some inherent limitations. Moreover, bias during the recruitment of purposive sampling cannot be ruled out. However, the results of the present study are generalizable and provide fruitful insight.


  Conclusion Top


Our findings indicate the severity of depression among the HIV/AIDS-positive people receiving free ART in the III and IV stage of the disease. Depression was found to be positively associated with avoidant coping. The subjects used avoidant coping strategies such as religion, ventilation, and behavioral disengagement. Women preferred religion, ventilation, and support coping more than men. The subjects rarely used active coping of positive reframing and planning. Results highlight the need to encourage active coping among HIV-infected people. High incidence of depression in PLWHA further aggravates the complications. Therefore, early diagnosis and management of depressive symptoms is an important factor for optimal outcome of treatment. As already proved, pharmacotherapy and psycho-social therapies (e.g., cognitive-behavioral therapy) were found effective for the treatment of severe depression. It underlines the need to make them as an integral part of HIV/AIDS routine health care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
United Nations Programme on HIV/AIDS. Global HIV/AIDS Response: Epidemic Update and Health Sector Progress Towards Universal Access; 2011. Available from: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20111130_UA_Report_en.pdf. [Last accessed on 2015 Dec 22].  Back to cited text no. 1
    
2.
National AIDS Control Organization (NACO). Annual Report 2013-14, Ministry of Health & Family Welfare, GOI. New Delhi; 2014. Available from: http://www.naco.govt.in. [Last accessed on 2015 Dec 22]  Back to cited text no. 2
    
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Angelino AF. Depression and adjustment disorder in patients with HIV disease. Top HIV Med 2002;10:31-35.  Back to cited text no. 8
    
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Unnikrishnan B, Jagannath V, Ramapuram JT, Achappa B, Madi D. Study of depression and Its associated factors among women living with HIV/AIDS in Coastal South India. ISRN AIDS 2012;2012:684972.  Back to cited text no. 9
    
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Simoni JM, Safren SA, Manhart LE, Lyda K, Grossman CI, Rao D, et al. Challenges in addressing depression in HIV research: Assessment, cultural context, and methods. AIDS Behav 2011;15:376-88.  Back to cited text no. 10
    
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Treisman G, Angelino A. Interrelation between psychiatric disorders and the prevention and treatment of HIV infection. Clin Infect Dis 2007;45 Suppl 4:S313-7.  Back to cited text no. 12
    
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Sternhell PS, Corr MJ. Psychiatric morbidity and adherence to antiretroviral medication in patients with HIV/AIDS. Aust N Z J Psychiatry 2002;36:528-33.  Back to cited text no. 13
    
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Sherbourne CD, Hays RD, Fleishman JA, Vitiello B, Magruder KM, Bing EG, et al. Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. Am J Psychiatry 2000;157:248-54.  Back to cited text no. 14
    
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Burns MJ, Feaster DJ, Mitrani VB, Ow C, Szapocznik J. Stress processes in HIV - Positive African American mothers: Moderating effects of drug abuse history. Anxiety Stress Coping 2008;21:95-116.  Back to cited text no. 17
    
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Swindells S, Mohr J, Justis JC, Berman S, Squier C, Wagener MM, et al. Quality of life in patients with human immunodeficiency virus infection: Impact of social support, coping style and hopelessness. Int J STD AIDS 1999;10:383-91.  Back to cited text no. 18
    
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Friedland J, Renwick R, McColl M. Coping and social support as determinants of quality of life in HIV/AIDS. AIDS Care 1996;8:15-31.  Back to cited text no. 19
    
20.
Beck A, Steer R, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation, Harcourt Brace & Company; 1996.  Back to cited text no. 20
    
21.
Carver CS. You want to measure coping but your protocol's too long: Consider the brief COPE. Int J Behav Med 1997;4:92-100.  Back to cited text no. 21
    
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Chandra PS, Desai G, Ranjan S. HIV & psychiatric disorders. Indian J Med Res 2005;121:451-67.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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