Psychiatric morbidity in HIV-positive subjects: A study from India

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Abstract

Objective

To study the psychiatric morbidity in HIV-positive subjects.

Design

Cross-sectional.

Methods

The purposive sample included HIV-positive subjects not receiving antiretroviral therapy (HIV) (n=100). Rheumatoid arthritis (severe) subjects not receiving steroids or disease-modifying antirheumatic drugs (RA) (n=40) were included as a comparison group. The 12-item General Health Questionnaire in Hindi (GHQ) was used to screen the psychiatric morbidity in both groups. In GHQ-positive cases, psychiatric diagnoses were made using the Structured Clinical Interview for DSM-IV (SCID).

Results

The HIV group reported sexual contact as the commonest source of infection (58%) and had a lower age at onset (32.53 vs. 36.60 years, P=.011), shorter duration of illness (12.95 vs. 83.37 months, P<.001), lower GHQ score (28.3 vs. 30.15, P=.043), similar Mini Mental State Examination (MMSE) score (28.01 vs. 27.37, P=.093) and lower psychiatric morbidity by both GHQ (score >2) (52% vs. 85%) and current SCID diagnoses (45% vs. 60%, P=.021), as compared to the RA group. The HIV group also had a lower prevalence of psychiatric disorders (45% vs. 60%), mood disorders [24% vs. 52% including major depressive disorder (19% vs. 45%)] and anxiety disorders (1% vs. 2.5%), but a higher prevalence of substance use disorders (17% vs. 2.5%), adjustment disorders (7% vs. 5%) and psychotic disorders (1% vs. 0), as compared to the RA group.

Conclusion

The high prevalence of psychiatric disorders, especially the mood disorders, in our HIV-positive subjects was generally similar to that reported from the rest of the world.

Introduction

The relationship between HIV-AIDS and psychiatric disorders is well recognized to be both uni- and bi-directional, and influenced by a variety of factors like stigma, educational level, concurrent substance abuse, presence of AIDS in the spouse, family support, neurocognitive disturbances, opportunistic infections and medication side-effects, treatment adherence and the course of HIV infection [1]. The introduction of highly active antiretroviral therapy (HAART) having transformed the HIV infection from a quickly fatal to a chronic disease [2] is another contributing variable.

One meta-analysis and other large studies in HIV-positive subjects reported prevalence rates of 20–50% for depressive symptoms, 4–23% for major depressive disorder (MDD), up to 13% for dysthymia and 2–40% for substance abuse/dependence (predominantly for alcohol) [3], [4], [5]. The HIV studies from the US have reported an annual prevalence of 47.9% for psychiatric disorders including MDD in 36%, dysthymia in 26.5%, generalized anxiety disorder in 15.8%, panic attacks in 10.5%, substance abuse in 21% and dual diagnosis in 8% subjects [6], [7].

In comparison, the prevalence of the commonest psychiatric syndrome, i.e., depression, has been reported as 2–56% in sub-Saharan Africa [8], [9], [10], [11], [12], [13], [14] and 10–40% in India [15], [16]. The variation is probably explained by the differences in study population, study design, age, sex, education, ethnicity and stage of HIV/AIDS [17]. One important factor in this context is the translation, modification and standardization of the Western assessment tools for the non-Western populations [18]. An example is the multilingual WHOQOL-100 questionnaire which shows similar basic factors inherent to the quality of life across cultures worldwide [19].

With a prevalence of 0.36% and 2.47 million afflicted persons, HIV-AIDS is a new epidemic in India [20]. Similar to the global scenario, the commonest route is the high-risk sexual behavior; except for the northeastern states where injecting drug use is a bigger contributor [21], [22]. Yet, the existing psychiatric research on HIV-AIDS in India has focused mostly on co-prevalence of intravenous drug abuse and, to a lesser extent, on psychiatric morbidity [1], [13], [23]. With this background, the present research attempted to assess the psychiatric morbidity in HIV-positive outpatient subjects in north India.

Section snippets

Location, ethical clearance, and design

The study was conducted at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, a 1500-bed multispecialty teaching hospital providing services to approximately 40 million people in north India.

As an MD Psychiatry research thesis of the first author, the research had received institutional ethical clearance, was time bound, and involved a cross-sectional design, a purposive sampling procedure, and one-time assessment of each subject.

Subjects

The sample consisted of

Demographic profile

The subjects in the HIV group were younger, less educated, and males, with higher proportion of skilled workers, Sikhs, and village dwellers than in the RA group (Table 1).

Disease profile

The self-reported source of HIV infection was most commonly sexual contact (58%, equal across men and women); 35% of subjects reported ‘not suspecting any source’; and injecting drugs, blood products, and artificial insemination were suspected only in 2%, 4%, and 1% of cases, respectively. The mean CD4 count at intake into

Discussion

The demographic profile of our HIV group generally matches the one reported from India [5], [32] and the West [33]. The nonheterosexual orientation in 2% of our sample tallies with a 2005 Indian report of homosexual transmission in 0.74% cases [34], although the Western studies report higher proportion of homo-/bisexuals (64.7–91%) [35], [36].

Compared to the literature, the rates in our HIV group are similar for depression (24% vs. 15.5–30%) [33], [34], [37], but lower for other disorders:

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    Disclaimer: No conflict of interest in this research. The researchers or this research was not funded by any agency.

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