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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 2  |  Page : 159-164

Predictors of depression among people living with HIV/AIDS on antiretroviral therapy attending tertiary care hospitals in the Capital of Uttar Pradesh: A cross-sectional study


1 Department of Community Medicine, Hind Institute of Medical Sciences, Ataria, Sitapur, Uttar Pradesh, India
2 Department of Community Medicine and Public Health, K. G. Medical University, Lucknow, Uttar Pradesh, India
3 Department of Clinical Hematology, K. G. Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication30-Jun-2017

Correspondence Address:
Mukesh Shukla
96 HA Vihar, Panigaon, Indira Nagar, Lucknow - 226 016, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.209200

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  Abstract 

Introduction: HIV/AIDS is one of the most devastating illnesses that humanity has ever faced. Depression in HIV/AIDS patients is very common but the factors affecting it are not well studied. Therefore, the present study aims to assess the prevalence and the predictors of depression among people living with HIV/AIDS (PLHA). Methods: A cross-sectional study was conducted from November 2013 to March 2014 at antiretroviral therapy centers of two tertiary care hospitals in Lucknow and a total of 322 adult HIV patients on antiretroviral treatment for at least 6 months were interviewed with the help of a predesigned and pretested schedule. Systematic random sampling was used to recruit the patients. Becks depression inventory was used to measure depression. Results: About one-fifth (18.6%) of the patients were having depressive symptoms. Multivariate logistic regression analysis revealed that depression was significantly associated with female gender (odds ratio [OR]: 3.45; 95% confidence interval [95% CI]: 1.50–7.90; P = 0.00), counseling gap more than 3 months (OR: 2.06; 95% CI: 1.14–4.21; P = 0.04), nonadherence to treatment (OR: 2.66; 95% CI: 1.47–6.19; P = 0.02), and socioeconomic status upper lower and below (OR: 2.08; 95% CI: 1.12–4.21; P = 0.04). Conclusions: Low socioeconomic status, female gender, long counseling gaps more than 3 months, and nonadherence to treatment were found to be important predictors of depression. Therefore, there is a need of timely assessment of the PLHA for depression to ensure early detection and management to maintain optimal adherence to the treatment.

Keywords: Antiretroviral therapy, depression, HIV/AIDS, people living with HIV/AIDS, predictors, prevalence


How to cite this article:
Shukla M, Agarwal M, Singh JV, Tripathi AK, Srivastava AK, Singh VK. Predictors of depression among people living with HIV/AIDS on antiretroviral therapy attending tertiary care hospitals in the Capital of Uttar Pradesh: A cross-sectional study. Indian J Soc Psychiatry 2017;33:159-64

How to cite this URL:
Shukla M, Agarwal M, Singh JV, Tripathi AK, Srivastava AK, Singh VK. Predictors of depression among people living with HIV/AIDS on antiretroviral therapy attending tertiary care hospitals in the Capital of Uttar Pradesh: A cross-sectional study. Indian J Soc Psychiatry [serial online] 2017 [cited 2022 May 28];33:159-64. Available from: https://www.indjsp.org/text.asp?2017/33/2/159/209200


  Introduction Top


HIV/AIDS is one of the most devastating illnesses that humanity has ever faced. Globally, 35.0 million (33.2–37.2 million) people were living with HIV at the end of 2013.[1] The Government of India estimates that about 2.40 million Indians are living with HIV (1.93–3.04 million) with an adult prevalence of 0.27% (2011).[2]

Depression is one of the most common neuropsychiatric complication of HIV disease.[3] HIV/AIDS and depression are projected to be the world's two leading causes of disability by 2030.[4] Prevalence of major depressive disorder among people living with HIV/AIDS (PLHA) varies from 20% to as high as 37%.[5],[6] With estimated 350 million people affected worldwide;[7] rates of depression are near about twice among people living with HIV than the general population (approximately 10% vs. 5%), as reported in a meta-analysis.[8] In context to Indian studies, the prevalence of depression varied from 23.48%[9] to 58.75%[10] among HIV patients. Depression in PLHA could be precipitated by stress, difficult life events, side effects of medications, or the effects of HIV on the brain and it might even accelerate HIV's progression to AIDS.[11],[12] Depression is associated with decreased health care utilization,[13] decreased the quality of life,[14] and increased suicidal tendency among patients.[15] Among PLHA, depression increases the likelihood of HIV transmission,[16] is often associated with poor adherence to antiretroviral therapy (ART),[17] leading to treatment failure,[18] and may independently increase HIV progression.[19] It is therefore necessary to identify patients with depression for proper and timely management. Unfortunately, in India, the services for HIV/AIDS patients are focused on somatic aspects of the disease and often neglect psychiatric manifestations, and depression is therefore underdiagnosed. This is due to the fact that prospective mental health is not effectively integrated into ART services program.

HIV/AIDS though such a big public health problem, not enough data are available regarding the association of HIV and depression especially in an Indian context. Therefore, this study was undertaken with the aim to assess the prevalence and predictors of depression among PLHA.


  Methods Top


Study design

The present study is a hospital-based cross-sectional study.

Study settings

The study was conducted at the ART Plus Center of King George's Medical University and ART Center of Ram Manohar Lohia Institute of Medical Sciences, two tertiary care hospitals in Uttar Pradesh. ART free of charge is provided at both these centers and are the relevant resources for CD4 count estimation, counseling sessions, and regular check-ups.

Study participants

PLHA patients from these centers aged ≥ 18 years, and who have been on ART for at least 6 months were included in the study.

Sample selection

Data were collected on 3 (alternate) days every week, during the study period from November 2013 to April 2014. Data collection days varied in consecutive weeks to reduce the bias for day-specific outpatient department attendance. Every sixth patient from the registration on that day was interviewed. If the patient was not eligible for this study, the next consecutive patient was interviewed in private. A total of 322 patients were included in the study. Nonwilling patients, patients who were unable to communicate and seriously ill patients were excluded from the study.

Ethical clearance

This study was approved by the Institutional Ethics Committee of King George's Medical University. Patients were briefed about the aims and objectives of the study and assured regarding the confidentiality of the data. Participants were interviewed after obtaining written consent.

Data collection tool

Patients were interviewed with the help of a predesigned and pretested schedule. The schedule was pretested on a sample of thirty patients on ART. Something which was confusing or inconsistent in the pretest exercise including the interview protocol was corrected before actual data collection and data regarding sociodemographic characteristics, social support, sexual behavior, and adherence to ART were collected. Results of pretest were not included in the final study. Completed schedules were checked weekly for consistency and completeness by the supervisors. The collected information was rechecked for its completeness and consistency before entering the data into a computer. Reliability test of the questionnaire was done with the same thirty patients on antiretroviral treatment. It was found consistent. Respondents have no problems in answering the questions.

Assessment of depression

Becks depression inventory (BDI) (Hindi) was used to assess depression in patients. The BDI demonstrates high internal consistency, with alpha coefficients of 0.86 and 0.81 for psychiatric and nonpsychiatric populations, respectively.[20] The BDI is a 21-item, self-report rating inventory that measures characteristic attitudes, and symptoms of depression. Higher scores on the scale indicated a greater number of depressive symptoms or a greater probability of major depressive disorder. The score range from 0 to 63. For the purpose of analysis, the score was dichotomized, with ≥ 17 being indicative of depression.

Assessment of nonadherence to antiretroviral therapy

Adherence percentage (A) was assessed using pill count method.

A = (Number of tablets or doses actually taken by a patient for a particular time period)/(Number of tablets or doses the patient should have taken during this time period).

All patients with poor adherence percentage <95% of treatment adherence were denoted as nonadherent.[21]

Data management

Data were compiled and analyzed using the statistical software SPSS version 16.0. The association between variables in relation to depression was determined using Pearson's Chi-square test; Yates corrected Chi-square and Fisher's exact test were applied in appropriate cases. Independent variables that were found to be statistically significant in bivariate analysis were considered for application in the logistic regression model to determine the important correlates, with depression as the dependent variable. A P ≤ 0.05 was considered statistically significant.


  Results Top


Biosocial characteristics of people living with HIV/AIDS

The mean age of the 322 patients participated in the present study was 38.3 ± 9.0 years. Almost half of the patients (44.7%) in the study were in the age group of 18–35 years. Few (10.6%) belonged to the age group >50 years. About 62.4% of the study population was male. Majority (76.0%) of the patients belonged to Hindu religion, with equal distribution (50% each) from rural and urban areas. Most of the patients (80.1%) were educated up to high school or below, of which 28.6% were illiterate. Almost half of the patients belonged to OBC category followed by 39.1% of unreserved category. Two-thirds of the patients (67.7%) were living in the nuclear family. The average family size was found to be five. The percentages of patients who were married, widowed, and separated were 63.4%, 24.8%, and 3.1%, respectively. In our study population, 34.8% of patients were unemployed.

Prevalence and predictors of depression

About one-fifth (18.6%) of the patient were having depressive symptoms, in which about 14% of the patients were suffering from moderate to severe depression. One patient in the study population was found to have extreme depression [Table 1].
Table 1: Distribution of patient attending antiretroviral therapy center on the basis of depressive symptoms (n=322)

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Univariate and multivariate logistic regression of the factors related to depression among sociodemographic factors

On univariate analysis, gender (P = 0.00), current employment status (P = 0.00), perception of side effects (P = 0.01), socioeconomic status (P = 0.00), time elapsed since last counseling (P = 0.01), and nonadherence to treatment (P = 0.00) were significantly associated with depression [Table 2].
Table 2: Univariate and multivariate analysis of the factors associated with depression (n=322)

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Multivariate logistic regression analysis revealed that depression was significantly associated with female gender (odds ratio [OR]: 3.45; 95% confidence interval [95% CI]: 1.50–7.90; P = 0.00), being counseled for adherence for more than 3 months, (OR: 2.06; 95% CI: 1.14–4.21; P = 0.04), nonadherence to treatment (OR: 2.66; 95% CI: 1.47–6.19; P = 0.02), and socioeconomic status upper lower and below (OR: 2.08; 95% CI: 1.12–4.21; P = 0.04). However, other factors such as current employment status and perception of side effects which were significant during bivariate analysis were found to be insignificant during multivariate analysis.


  Discussion Top


The depressive symptoms were present in 18.6% of the study population which was lower than that reported in other studies in India viz., Srivastava [9] and Bhatia [10] (23.48% and 58.75%, respectively). It was also lower than L'akoa et al.,[22] Ouedraogo and Sanou,[23] and Kaharuza et al.,[24] respectively, who found a prevalence of 63% in Cameroon, 51.3% in Burkina Faso, and 47% in Uganda. These variations might be due to the difference in sample size or diagnostic criteria used by studies in making a diagnosis of depression, for example, while some study used Center of Epidemiological Studies Depression;[10] some other used Patient Health Questionnaire.[22]

Similar to other studies female preponderance was found to be associated with a 3–4 times higher chance of depression than males.[25],[26],[27] Shittu et al.[27] opined that this might be attributed to the fact that women are more likely to experience negative social determinants than men because they have a double burden of raising children and household work. However, the result of the present study was in paradox to the findings of that in Africa where depression was higher among males.[28] On the other hand, Indian studies reported no difference in symptomology of depression in the two sexes.[9],[10]

In the present study, the prevalence of depression was found to be double among the low socioeconomic group. Similar findings were reported in other studies also.[10],[25] Offord et al. opined that overall living condition, including income, affects one's psychological condition.[25] Low-income people residing in underprivileged conditions cannot afford healthy food, sufficient clothing, and good housing condition for themselves as well as their families, all of which indirectly determine the preconditions of good health.

Although good social relationship makes an important contribution to health and provides people the emotional resources needed and the majority of the studies; both Indian as well as global reported social support to be an important contributor in preventing depression, in the present study association between social support and depression was found to be statistically insignificant.[10],[27],[29],[30]

As employment helps in income generation and thereby leads to social and economic stability and a sense of self-esteem in a person, several studies reported depression more among unemployed patients.[10],[24],[31] However, in the present study, association between employment and depression lost its significance during multivariate analysis.

Depression was found to be of about 2-fold higher prevalence among patients who were last counseled more than 3 months ago. This might be attributed to the fact that counseling had a big role to play in the overall health of the PLHA. Along with guidance, decision making, and problem sharing, counseling provides a sort of social support along with emotional and practical resources that PLHAs need.

Similar to other studies depression was found to be significantly associated with adherence to treatment.[10],[32],[33] This might be attributed to the fact that proper adherence to ART improved the quality of life among the patients hence leading to good mental health. Moreover, vice-versa, early detection and effective treatment of depression goes a long way in improving the adherence to ART and thus improving the quality of life.[10]

Limitations

This study has some limitations. Selection bias may have occurred, as only those PLHA who were on ART at the time of data collection were included, whereas those who were lost to follow-up or could not attend the ART Center to collect drugs or those who were not on ART were not enrolled in the study. Second, the patients with the chronic physical disorder (including HIV) are more likely to have the influence of somatic symptoms on their mental status which may lead to depressive symptoms. In addition, as the study was conducted in hospital settings therefore its generalizability is limited.


  Conclusions Top


Long counseling gaps more than 3 months, low socioeconomic status, female gender, and nonadherence to treatment were found to be important predictors of depression.

Recommendations

Overall our findings indicate a significant level of depressive symptoms among PLHAs on ART. This highlights the need of effective mental health services to be incorporated into routine ART services. This will lead to early detection and proper management of depression since it may enhance linkage and retention to ART services. There is a need to focus especially on females. Frequent and comprehensive counseling sessions will help PLHAs to cope with situations leading to psychological instability, hence preventing depression.

Acknowledgments

I am thankful to Dr. Neetu Gupta, Dr. Suman Shukla, Medical Officer ART Center, Mrs. Rajnigandha, Counselor, ART Center, King George's Medical University, Lucknow, Dr. Abhishek Gupta, Dr. Pallavi Shukla, Dr. Kanchan, and Dr. Ravikant and my dear juniors for their constant encouragement and motivation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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