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The Health Agenda, Volume 2. Issue 2. April, 2014
ORIGINAL ARTICLE
Burden of depression among patients on HAART
Author: Harshal Sabane
Corresponding author: Dr. Harshal Sabane
Lecturer, Department of Epidemiology and Public Health
Oman Medical College, Sohar, Oman
Mail ID: [email protected]
ABSTRACT
Introduction: AIDS is one of the most destructive pandemics in recorded history. The burden of mental
health problems is rapidly increasing and it is experienced more by the PLHAs. Depression is among the
major contributors towards this morbidity. It is also significantly associated with the practice of high risk
behaviour like intravenous drug abuse, needle sharing, to have sex when high on alcohol or drugs and
reduced adherence to medication. Objective: To determine prevalence of depression in PLHAs and to
give suitable recommendations based on the study findings. Methodology: The cross-sectional study was
done in a tertiary level hospital setting with patients who were enrolled with the hospital for treatment of
AIDS. An interviewer administered questionnaire was used to collect the data and DSM IV criteria for
depression was used to diagnose major depressive episode. Statistical analysis was done using Epi.Info
7.1.2. Results: The prevalence of depression in the study subjects was found to be 14.28%. The
association of depression with substance abuse was found to be statistically significant (p=0.02).
However, the association of depression with gender was not found to be statistically significant (p=0.11).
Conclusion: Depression is a significant co-morbidity in AIDS patients. Efforts should be targeted towards
early identification and prompt treatment of depression to improve the outcome of the patients.
Key words: AIDS, Depression, Drug abuse, HIV, PLHA
INTRODUCTION
Acquired
Immunodeficiency
Syndrome
(hereafter AIDS) is one of the most destructive
pandemics in recorded history. The official date
for the beginning of the AIDS epidemic is
marked as June 5, 1981, when the US Centre for
Disease Control and Prevention reported in its
‘Morbidity and Mortality Weekly Report’
newsletter, that an unusual cluster of
Pneumocystis carinii pneumonia had been
discovered in gay men in Los Angeles in the
early 1980s. (1)
management. It has remarkably improved the
prognosis of HIV infection. The goal of therapy is
to achieve an undetectable viral load after the
administration of combination HAART therapy.
(3,4) Depression is more prevalent in HIV seropositives as compared to HIV sero-negatives. (5-7)
It is also significantly associated with the
practice of high risk behaviour like intravenous
drug abuse, needle sharing, to have sex when
high on alcohol or drugs and reduced adherence
with HAART. (8-11)
HIV is a pandemic today with majority of the
affected living in the poor developing countries
like India. It is not only a biological ailment. It
also has a social and a cultural dimension. HIV
infection was first identified in India in 1986,
when serological testing found that 10 of 102
female sex workers in Chennai were HIV
positive. (2) HAART (Highly Active Anti-retroviral
Therapy) has led to substantial reduction in HIV
associated morbidity and HIV infection has
entered the stage of chronic disease
OBJECTIVE
The Health Agenda, Online ISSN No: 2320-3749
To determine prevalence of depression in HIV
positive patients.
METHODOLOGY
A cross-sectional study was carried out at a
tertiary care referral hospital catering to all
disciplines of allopathic medicine. Since the
study involved human subjects, ethical clearance
was obtained from the Institutional Ethical
Review Committee of the parent institution.
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Sabane H: Burden of depression among patients on HAART
The study involved 308 HIV positive OPD and
IPD patients who were on HAART for more than
3 months. Patients who were on HAART for less
than 3 months, patients who were unable to
comprehend, patients who refused to give
consent and paediatric patients were excluded
from the study. The hospital has a specialist OPD
for HIV and AIDS patients. Free HAART
treatment is not available at the hospital. The
investigator was trained in the Department of
Psychiatry before beginning of the study to use
and score DSM IV scale for diagnosis of
depression.
After establishing a rapport, the patients were
briefed about the study and its objective.
Informed consent of the patients was taken and
thereafter patients were registered for the
study. Preliminary information was obtained
followed by detailed history recorded on a pretested interviewer administered structured
questionnaire. Diagnostic and Statistical Manual
IV edition was used to diagnose major
depressive episode. It is an objective scale of
diagnosing depression. The scale is a nine point
instrument. Scores ≥5 are indicative of major
depressive episode. Patients who were
diagnosed with depression were referred to the
psychiatric OPD for further management.
Statistical analysis was done using Epi.Info
version 7.1.2.
RESULTS
Among total 308 study subjects, 262 (85.06%)
were male and 46 (14.94%) were female. 237
(76.95%) subjects belonged to age group 21-40
years; only 4 (1.29%) were in 51-60 years of age
group. 96 (31.17%) subjects were semi-skilled
workers. 110 (35.70%) were employed in better
jobs consisted of skilled, semi-professionals and
professionals. Majority of the study subjects
(32.14%) belonged to social class III according
to Prasad’s scale. It was followed by social class
IV (30.15%). Prasad’s scale was used for the
socioeconomic classification of the study
population as the study was conducted in a
hospital based setting.
Majority of the study subjects (50.65%) were
educated up to high school and intermediate
grade. Percentage of patients having graduation
and post-graduation was 15.90%. 282 (91.56%)
of the study subjects in the present study were
married. 301 (98.05%) study subjects were on
non-protease inhibitor based regimen. 181
(58.76%) were on Stavudine, Lamivudine and
Nevirapine, 58 (18.83%) were on Zidovudine,
Lamivudine and Nevirapine, 51 (16.55%) on
Efavirenz based regimen and 12 (3.89%) on
other NRTI/NNRTI based combinations. Only 7
(1.94%) patients were on protease inhibitor
based treatment.
Tables 1: Distribution of study subjects according to age and sex
Study subjects
Age group (in years)
Male (%)
Female (%)
21-30
104 (33.76)
12 (3.89)
31-40
105 (34.05)
16 (5.19)
41-50
49 (15.90)
18 (5.85)
51-60
4 (1.29)
0
Total
262 (85.06)
46 (14.94)
Table 2: Distribution of study subjects according to depression
Depressed
Yes
No
Table 3: Association of depression with gender
Depressed
Gender
Yes (%)
No (%)
Male
34 (12.98)
228 (87.02)
Female
10 (21.74)
36 (78.26)
Total
44 (14.28)
264 (85.72)
(Chi square value=2.45, df=1, p=0.11)
Total (%)
116 (37.66)
121 (39.29)
67 (21.76)
4 (1.29)
308 (100)
N (%)
44 (14.28)
264 (85.72)
Total (%)
262
46
308
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The Health Agenda, Volume 2. Issue 2. April, 2014
Table 4: Association of depression with substance abuse
Substance abuse
Depression
Yes (%)
No (%)
Yes
38 (86.36)
6 (13.64)
No
184 (69.69)
80 (30.31)
Total
222 (72.07)
86 (27.93)
(Chi square value=5.21, df=1, p=0.02)
The prevalence of depression in the study
subjects as per DSM IV scale was found to be 44
(14.28%). It was observed that amongst the
depressed majority were male. The association
of depression with gender was statistically not
significant.
260 (84.41%) subjects had history of multiple
sexual partners. 141 (45.77%) subjects had
more than 3 sexual partners. 48 (15.58%)
subjects had one sexual partner. Almost all the
subjects who had single sexual partner were
females who had been infected by their
partners.
Depressed subjects were more likely to indulge
in substance abuse as compared to normal
subjects. Subjects who indulged in any form of
substance abuse including smoking, tobacco
chewing, alcohol and intra venous drug abuse
were included as positive. In the present study,
87 (28.24%) subjects were using tobacco in one
or the other form. 43 (13.96%) gave history of
alcohol consumption. 92 (29.87%) subjects gave
history of both tobacco and alcohol
consumption. 4 (1.29%) subjects were addicted
to intra venous drugs. The association of
depression with substance abuse was found to
be statistically significant.
DISCUSSION
Today, AIDS has become a manageable chronic
illness rather than a disease causing sure and
rapid death. (12) The advent of HAART has
changed the face of the disease, and the way
patients look at it. However, an increasing
number of clinical and epidemiological studies
have implicated depression as a potential risk
factor in the morbidity and mortality among
patients with HIV infection. (7,13)
The reason for excessive male preponderance in
the present study might be because of higher
prevalence of HIV in males as compared to
females in the general population. NFHS-3
Total (%)
44
262
308
survey has also reported higher prevalence in
males (0.43%), as compared to females (0.29%).
(2) There could have been more health seeking
behaviour in males. Almost all the study subjects
with tobacco use and alcohol consumption were
males. All four intra venous drug abusers were
also males. Tobacco use also hampers the action
of the HAART medication. (14) All four intra
venous drug abusers were non adherent to
treatment in the study. This was a significant
finding because counselling against substance
abuse is a significant part of mental preparation
of the patients who are to be put on HAART.
Many patients still indulged in substance abuse
in spite of the counselling. In the hospital free
HAART was not available and patients had to
bear the cost of the treatment out of pocket. The
hospital has no specific catchment area.
Therefore there is inflow of both rural and
urban population at the hospital.
The findings of the study have to be looked upon
with consideration to the limitations of the
study. The findings of the study may not be
generalized to all areas as different clinical
settings will have different populations. Also, the
profile of patients attending an ART clinic where
free treatment is unavailable is expected to be
systematically different from clinics where such
facilities exist. The diagnosis of depression is a
challenging task in patients of AIDS as some of
the somatic symptoms of AIDS may mimic the
clinical features of depression which are
included in the questionnaire.
CONCLUSION
Many patients undergoing treatment with
HAART are suffering with depression.
Depression is also significantly associated with
substance abuse. Early diagnosis and prompt
management of such patients may result in
better clinical outcome. Emphasis on counselling
and identification of patients, likely to be
suffering from depression should be highlighted.
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Sabane H: Burden of depression among patients on HAART
Acknowledgement: Author would like to thank
Dr. SP Pitale, Associate Professor, Department of
Community Medicine and Dr. Sushil Gawande,
Assistant Professor, Department of Psychiatry
for training the author in administration and
interpretation of various scales of depression
including Hamilton’s scale and the DSM IV scale.
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Particulars of Contributor:
Dr. Harshal Sabane, Lecturer
Department of Epidemiology and Public Health
Oman Medical College, Sohar, Oman
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Source of funding: Nil
Conflict of interest: None
Date of Submission:
Date of Acceptance:
Date of Publishing:
12 February, 2014
2 April 2014
6 April 2014
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