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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. Page | 62 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 Page | 63 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. Page | 64 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. REFERENCES 1. Detels R, McEwen J, Beaglehole R, Tanaka H. Oxford Textbook of Public Health. 4th ed. Oxford, U.K.: Oxford University Press; 2004. 2. National Family Health Survey-3, HIV/AIDSrelated knowledge, attitudes, and behaviour. NFHS-3 (2005-06), MoHFW, Govt. of India. [Online] [cited 4 April 2014]. Available from: http://hetv.org/india/nfhs/nfhs3/ NFHS-3-Chapter-11-HIV-AIDS-RelatedKnowledge-Attitudes-and-Behaviour.pdf 3. 4. 5. Glass TR, De Geest S, Weber R, et al. Correlates of self-reported nonadherence to antiretroviral therapy in HIV-infected patients. 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AIDS Patient Care STDS. 2008;22(4):313-21. 14. Brennan C. Smoking can have negative impact on immune response to HAART. HIV Clin. 2013;25(1)6-9. 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 Page | 65