INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 48(4) 253-261, 2015
DEPRESSION AND CD4 CELL COUNT AMONG PATIENTS WITH HIV IN A NIGERIAN UNIVERSITY TEACHING HOSPITAL
VICTOR OBIAJULU OLISAH, MBBS OLUWATOSIN ADEKEYE, MSC Ahmadu Bello University Teaching Hospital, Zaria, Nigeria TAIWO LATEEF SHEIKH, MBBS Federal Neuropsychiatric Hospital, Barnawa, Kaduna, Nigeria
ABSTRACT
Objective: Depression is common in people living with HIV/AIDS and there is some evidence that depressive symptoms may have adverse effects on immune functioning. The purpose of this study was to determine the prevalence of current depressive disorder in patients with HIV/AIDS and its association with CD4 cell count. Methods: A consecutive sample of 310 patients with HIV/AIDS attending Out-patient clinic in Ahmadu Bello University Teaching Hospital (A.B.U.T.H.), Zaria, Nigeria was assessed. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to screen for depressive symptoms, and the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) was used to confirm the diagnosis of current depressive disorder. The CD4 cell counts of participants with depressive disorder were compared with those of participants without depressive disorder. Multiple regression analysis was conducted to identify sociodemographic and disease-related factors associated with depression. Results: Among the 310 HIV-infected participants assessed for depression, 14.2% had current depressive disorder. Adjusting for age, gender, education, occupation, and marital status, patients with CD4 counts < 150 cells/ml were more likely to be depressed. Conclusion: Depression is common among 253 Ó 2015, The Author(s) doi: http://dx.doi.org/10.2190/PM.48.4.b ijpm.sagepub.com
254 / OLISAH, ADEKEYE AND SHEIKH
HIV-infected persons in Nigeria and is associated with low CD4 cell counts. The screening and treatment of mental health problems such as depression should be considered an integral component of HIV care and support. (Int’l. J. Psychiatry in Medicine 2014;48:253-261)
Key Words: current depressive disorder, CD4 cell count, HIV/AIDS
INTRODUCTION Nigeria has the second highest number of new HIV infection cases reported each year, with an estimated 3.7% of the population living with HIV/AIDS [1, 2]. Despite the importance of mental illness and the high prevalence of HIV in Africa, only a few studies have documented depressive disorder among HIV-infected persons in Africa, especially with reference to its impact on CD4 count and immune functioning. The prevalence of depression in HIV clinic population in a Nigerian study was 28.7% [3] and ranges from 22% to 32% in a study done in the United States [4]. Also, meta-analysis provides strong evidence that HIV infection is associated with a greater risk for major depressive disorder [5]. Depression is the fourth leading cause of disease burden, accounting for 4.4% of total Disability Adjusted Life Years (DALYs) in the year 2000 [6]. The combined burden from depression and HIV infection will lead to severe suffering in patients and impact negatively on disease outcomes. The relationship between depression and HIV/AIDS may be complex. Firstly, populations at risk for HIV infection have elevated rates of major depression. High rates of major depression have been found in homosexual men [7, 8] and patients with substance use disorders [9]. Secondly, major depression is a risk factor for HIV infection by virtue of its impact on behavior, intensification of substance abuse, exacerbation of self-destructive behaviors, and promotion of poor partner choice in relationships [10, 11]. In this way, depression can be seen as a vector of HIV transmission. Thirdly, HIV increases the risk of developing major depression through a variety of mechanisms, including direct injury to sub-cortical areas of the brain, chronic stress, stigma, worsening social isolation, bereavement, debilitation, and intense demoralization [12]. An accumulating body of data now shows that depression may have an impact on morbidity and mortality among individuals with HIV disease. Although the specific physiologic mechanisms involved in this process have not been delineated, there is some evidence to suggest that depression reduces several in vitro measures of immune function including the killer lymphocytes such as CD8+ T lymphocytes and natural killer cells, and this may represent the key pathways through which depression affects HIV disease progression [13, 14]. Many studies have shown an increase in the prevalence rates of depression as CD4 count declines in patients with HIV/AIDS. The Multicenter AIDS Cohort
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255
Study showed a two-and-half-fold increase in rates of depression as patients CD4 cell count fall below 200 cells per mm3 [15]. Another study in Uganda found, after adjusting for age, gender, education, and source of income, that HIV patients with CD4 counts < 50 cells/mm3 were more likely to be depressed (odds ratio 2.34, 95% confidence interval, 1.39-3.93, P = 0.001) [16]. Some other studies, however, did not find this association [17, 18]. The purpose of this study is to determine the prevalence of current depressive disorder and its association with CD4 cell count in patients with HIV/AIDS attending an outpatient clinic in Northern Nigeria. This study will help create awareness among clinicians involved in the care of people living with HIV/AIDS about depression in HIV infection and its relevance to the immune status and disease progression. This will help to promote interventions that will enhance routine screening, early diagnosis, and treatment of depression in this group of patients. METHODOLOGY A descriptive cross-sectional study design was conducted at Virology outpatient clinic at the Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria. The hospital is a 1000-bed capacity tertiary health facility located in Shika, a predominantly Hausa speaking rural community. Although being the main tertiary health facility in Northwestern Nigeria, the population attending the hospital is largely cosmopolitan. Beginning with the first patient on the list of daily HIV clinic attendance, every consecutive patient who met eligibility criteria and gave informed consent was recruited and interviewed until the sample size of 310 participants was attained. This sample size was calculated using the formula for calculating minimum sample size in cross-sectional studies based on the assumption of prevalence rate of 38.7% for depression in patients with HIV from a previous study (19): n=
Z2 P q D2
(20)
The Ethics and Research Committee of the University Teaching Hospital approved the study protocol and duly signed informed consents were obtained from the participants after the aims and objectives of the study had been explained. Eligibility criteria included patients with confirmed HIV infection who were on antiretroviral medication; the study excluded patients receiving treatment for other co-morbid chronic medical conditions in their medical records, patients seeing a mental health professional for any other neuropsychiatric conditions besides depression, and those found to have marked cognitive impairment following a mental state examination. Participants found to have impaired memory and disorientation in person, place, or time were excluded from the study.
256 / OLISAH, ADEKEYE AND SHEIKH
Socio-demographic questionnaire was administered to all the qualifying participants. Each was screened for depressive symptoms using the Center for Epidemiologic Studies Depression Scale Revised (CES-DR) instrument. The CES-DR is an instrument used in epidemiological studies as a screening tool for depressive symptomatology. Participants with a CES-DR score ³ 16 were considered as having significant depressive symptoms and were then administered the depression module of the Schedule for Clinical Assessment in Neuropsychiatry (SCAN). The SCAN is a WHO structured diagnostic instrument used for assessing, measuring, and classifying the psychopathology and behavior associated with the major psychiatric disorders of adult life. The most recent documentation of participants’ CD4 cell count results from the hematology laboratory of the hospital was obtained from their medical records. All questionnaires were translated into Hausa language for patients with low education and interviewer administered by a single trained investigator over a 5-month period. SPSS-16 software was used for data entry and analysis. Chi-square test was used to characterize the significance of the association between depressive disorder and CD4 cell count while multiple regression analysis was used to test the value of CD4 cell count as a predictor for depressive disorder in the participants. All the participants completed the assessment. RESULTS A total of 310 patients with HIV participated in the study. The mean duration of their illness (i.e., time since HIV diagnosis) was 26.5 months (± 8.9), and mean duration on antiretroviral therapy (ART) was 17.7 months (± 5.2). The socio-demographic characteristics of participants showed that 31.6% were males, 52.9% were married, 38.7% were unemployed, mean age was 35.5 years ± 8.97, and 64.5% had at least a secondary education. See Table 1. The results show that 21.3% (n = 66) of the participants had significant depressive symptoms (i.e., CES-DR score >16). Also, 14.2% (n = 44) of the total met the diagnostic criteria for depressive disorder (based on the RDC). Kappa statistics between those identified as depressed through the CESD-DR and the ICD-10 criteria was 0.759, signifying good agreement. The CD4 cell counts of participants with depressive disorder were compared with those of participants without depressive disorder as shown in Table 2. A significant association was found between depression and low CD4 cell count (c2 = 30.257, df = 1, p < 0.05). Multiple regression was run to test predictors of depressive disorder based on gender, age, occupation, marital status, education, and CD4 count as shown in Table 3. These variables jointly and significantly predicted depression, F(6, 95) = 35.193, p < .05, R2 = 0.62. CD4 cell count significantly predicted depression (beta = 0.58, p < .05) accounting for 58%.
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257
Table 1. Socio-Demographic Characteristics of Participants Variable
n (%)
Sex Males (mean age 40.1 years ± 8.8) 98 (31.6) Females (mean age 33.4 years ± 8.2) 212 (68.4) Mean age overall: 35.5 years ± 8.97 Religion Islam Christianity
124 (40) 186 (60)
Marital status Single Married Divorced Widowed Separated
66 (21.3) 164 (52.9) 14 (4.5) 64 (20.6) 2 (0.6)
Occupation Unemployed Unskilled worker Petty trader Semi-skilled worker Highly skilled professional Retired
120 (38.7) 29 (9.4) 48 (15.5) 22 (7.1) 85 (27.4) 6 (1.9)
Education Primary school Secondary school Tertiary Arabic schooling No schooling
62 (20) 116 (37.4) 84 (27.1) 20 (6.5) 28 (9)
DISCUSSIONS Most of the patients with HIV in this study had had a relatively short illness and treatment duration (mean = 26.5 months and 17.7 months, respectively). This may be a reflection of the recent efforts in Nigeria by government and nongovernmental organizations and international agencies to promote voluntary counseling and testing, public education about HIV and AIDS, and free antiretroviral therapy for people who need it.
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Table 2. CD4 Count of Subjects With Depressive Disorder and Those Without Depressive Disorder Diagnosis Depressive disorder
No depressive disorder
0–150 cells/mm3
24 (54.5%)
60 (22.6%)
cells/mm3
20 (45.5%)
206 (77.4%)
>150
c2 = 30.257, df = 1, p £ 0.05.
Table 3. Socio-Demographic and CD4-Related Factors Associated with Depression: Multiple Regression Results Variable
Beta
Multiple R2
Adjusted R2
F ratio
p-Value
Age
0.04
0.62
0.61
35.193
.000
Gender
0.20
Marital status
0.15
Occupation
0.12
Education
0.02
CD4 count
0.58
F(6, 95) = 35.193, p < .05, R2 = 0.62.
The prevalence of depressive disorder in the participants was 14.2%. Other studies have likewise found increased prevalence of depression in people living with HIV/AIDS [3, 4]. However, the relatively lower prevalence for depressive disorder observed in this study compared to the 28.7% reported by Adewuya et al. [3] in Southern Nigeria or the 22 to 32% reported in some studies in the United States [4] may be due to the case ascertainment method used and the category of patients studied in terms of their stage of HIV disease. Studies have shown that increased prevalence of depressive disorder in people living with HIV may be due to the effects of the virus on the sub-cortical areas
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259
of the brain, chronic stress experienced by patients with HIV/AIDS resulting from unemployment, poor financial security, burden of care due to the disease, stigmatization, bereavement, and intense demoralization [12]. The study found a significant association between depressive illness and low CD4 cell count. Also, CD4 cell count was the most significant predictor for depression similar to findings in other studies [15, 16]. This may be due to the negative effects of depression on immune status which may consequently result in HIV disease progression [13, 14]. The study suggests that depression is common in people living with HIV/AIDS in Nigeria and is associated with declining CD4 cell count with serious consequences on disease progression. Unfortunately, mental health services are provided by few tertiary health centers scattered around the country which is grossly inadequate for the teaming population. Again, mental health integration in primary healthcare in Nigeria is rudimentary and most HIV response in the country has excluded mental health aspects. Studies have shown that significant numbers of HIV-infected people have, or develop, mental health problems, and this often adversely impacts on HIV/AIDS treatment. A more prominent role is needed for mental health interventions in global HIV/AIDS initiatives. Integrating psychiatric and psychosocial interventions should benefit both the mental and the physical health of people living with HIV/AIDS. Therefore, physicians involved in the care of people with HIV or AIDS should routinely assess their patients for psychiatric morbidity, especially depression using simple screening instruments, so as to facilitate appropriate and holistic care. This study was limited by the fact that it is hospital-based and the results may not be generalized to the entire population of PLHIV. Secondly, the authors did not control for the somatic items in the CES-D and this might have confounded the measure of depression. Also, the categorization of CD4 cell counts (a continuous variable) during data analysis may give a slightly biased result.
REFERENCES 1. UNAIDS Global report. UNAIDS Report on Global AIDS Epidemic, 2012. 2. Federal Republic of Nigeria. Global AIDS Response Country Progress Report, Nigeria, 2012. 3. Adewuya AO, Afolabi MO, Ola BA, Ogundele OA, Ajibare AO, Oladipo BF, Fakande I. Relationship between depression and quality of life in persons with HIV infection in Nigeria. International Journal of Psychiatry in Medicine 2008;38(1): 43-51. 4. Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London SA, Turner BJ, Eggan F, Beckman R, Vitiello B, Morton SC, Orlando M, Bozzette SA, Ortiz-Barron L, Shapiro M. The estimated prevalence of psychiatric disorders, drug use and dependence among people with HIV disease in the United States. Archives of General Psychiatry 2001;58:721-728.
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5. Ciesla MA, Robert JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. American Journal of Psychiatry 2001;158(5): 725-730. 6. Ustun TB, Ayuso-Mateos JL, Chatterji S, Mathers C, Murray JL. Global burden of depressive disorders in year 2000. British Journal of Psychiatry 2004;184: 386-392. 7. Sittirai W, Brown T, Sakondhavat C. Level of HIV risk behavior and AIDS knowledge in Thai men having sex with men. AIDS Care 1993;5(3):261-271. 8. Markowitz JC, Klerman GL, Clougherty KF, Spielman LA, Jacobsberg LB, Fishman B. Individual psychotherapies for depressed HIV-positive patients. American Journal of Psychiatry 1995;152:1504-1509. 9. McKinon K, Cournos F, Sugden R, Guido JR, Herman R. The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness. Journal of Clinical Psychiatry 1996;57(11): 506-513. 10. Kelly JA, Murphy DA, Bahr GR, Koob JJ, Morgan MG, Kalichman SC, Stevenson LY, Brasfield TL, Bernstein BN, St Lawrence JS. Factors associated with severity of depression and high risk sexual behavior among persons diagnosed with human immunodeficiency virus infection. Health Psychology 1993;12:215-219. 11. Kalichman SC, Kelly JA, Rompa D. Continued high risk sex among HIV seropositive gay and bisexual men seeking HIV prevention services. Health Psychology 1997;16:369-373. 12. Zisook S, Peterkin J, Goggin KJ, Sledge P, Atkinson JH, Grant I. Treatment of major depression in HIV positive men. Journal of Clinical Psychiatry 1998;59: 217-224. 13. Cruess DG, Dauglas SD, Petitto JM, Lesserman J, Ten Have T, Gettes DR, Dube B, Evans DL. Association of depression, CD+ 8 T lymphocytes and natural killer cell activity: Implications for morbidity and mortality in HIV disease. Current Psychiatry Reports 2003;5(6):445-450. 14. Cruess DG, Petitto JM, Lesserman J, Dauglas SD, Gettes DR, Ten Have TR, Evans DL. Depression and HIV infection: Impact on immune function and disease progression. CNS Spectrums 2003;8(1):52-58. 15. Lyketsos CG, Hoover DR, Guccione M, Dew MA, Wesch JE, Bing EG, Treisman GJ. Changes in depressive symptoms as AIDS develop. American Journal of Psychiatry 1996;153:1430-1437. 16. Kaharuza FM, Bunnell R, Moss S, Purcell DW, Bikaako-Kajura W, Wamai N, Downing R, Solberg P, Coutinho A, Mermin J. Depression and CD4 cell count among persons with HIV infection in Uganda. AIDS & Behavior 2006;10(4): S105-S111. 17. Rabkin JG, Goetz RR, Remien RA, Williams JB, Todak G, Gorman JM. Stability of mood despite HIV illness progression in a group of homosexual men. American Journal of Psychiatry 1997;154:231-238. 18. Fincham D, Smit J, Carey P, Stein DJ, Seedat S. The relationship between behavioral inhibition, anxiety disorders, depression and CD4 counts in HIV positive adults: A cross-sectional controlled study. AIDS Care 2008;20(10):1279-1283. 19. Olley BO, Gxamza F, Seedat S, Reuter H, Stein DJ. Psychiatric morbidity in recently diagnosed HIV patients in South Africa. South African Medical Research Council Publication; AIDS Bulletin 2003;12(1):12-16.
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20. Araoye MO. Research methodology with statistics for health and social sciences. Ilorin, Nigeria: Nathadex Publishers, 2004:117-120.
Direct reprint requests to: Dr. Victor Obiajulu Olisah Department of Psychiatry Ahmadu Bello University Teaching Hospital Zaria, P.M.B 06 Zaria, Kaduna State, Nigeria e-mail: [email protected]
DEPRESSION AND CD4 CELL COUNT AMONG PATIENTS WITH HIV IN A NIGERIAN UNIVERSITY TEACHING HOSPITAL
VICTOR OBIAJULU OLISAH, MBBS OLUWATOSIN ADEKEYE, MSC Ahmadu Bello University Teaching Hospital, Zaria, Nigeria TAIWO LATEEF SHEIKH, MBBS Federal Neuropsychiatric Hospital, Barnawa, Kaduna, Nigeria
ABSTRACT
Objective: Depression is common in people living with HIV/AIDS and there is some evidence that depressive symptoms may have adverse effects on immune functioning. The purpose of this study was to determine the prevalence of current depressive disorder in patients with HIV/AIDS and its association with CD4 cell count. Methods: A consecutive sample of 310 patients with HIV/AIDS attending Out-patient clinic in Ahmadu Bello University Teaching Hospital (A.B.U.T.H.), Zaria, Nigeria was assessed. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to screen for depressive symptoms, and the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) was used to confirm the diagnosis of current depressive disorder. The CD4 cell counts of participants with depressive disorder were compared with those of participants without depressive disorder. Multiple regression analysis was conducted to identify sociodemographic and disease-related factors associated with depression. Results: Among the 310 HIV-infected participants assessed for depression, 14.2% had current depressive disorder. Adjusting for age, gender, education, occupation, and marital status, patients with CD4 counts < 150 cells/ml were more likely to be depressed. Conclusion: Depression is common among 253 Ó 2015, The Author(s) doi: http://dx.doi.org/10.2190/PM.48.4.b ijpm.sagepub.com
254 / OLISAH, ADEKEYE AND SHEIKH
HIV-infected persons in Nigeria and is associated with low CD4 cell counts. The screening and treatment of mental health problems such as depression should be considered an integral component of HIV care and support. (Int’l. J. Psychiatry in Medicine 2014;48:253-261)
Key Words: current depressive disorder, CD4 cell count, HIV/AIDS
INTRODUCTION Nigeria has the second highest number of new HIV infection cases reported each year, with an estimated 3.7% of the population living with HIV/AIDS [1, 2]. Despite the importance of mental illness and the high prevalence of HIV in Africa, only a few studies have documented depressive disorder among HIV-infected persons in Africa, especially with reference to its impact on CD4 count and immune functioning. The prevalence of depression in HIV clinic population in a Nigerian study was 28.7% [3] and ranges from 22% to 32% in a study done in the United States [4]. Also, meta-analysis provides strong evidence that HIV infection is associated with a greater risk for major depressive disorder [5]. Depression is the fourth leading cause of disease burden, accounting for 4.4% of total Disability Adjusted Life Years (DALYs) in the year 2000 [6]. The combined burden from depression and HIV infection will lead to severe suffering in patients and impact negatively on disease outcomes. The relationship between depression and HIV/AIDS may be complex. Firstly, populations at risk for HIV infection have elevated rates of major depression. High rates of major depression have been found in homosexual men [7, 8] and patients with substance use disorders [9]. Secondly, major depression is a risk factor for HIV infection by virtue of its impact on behavior, intensification of substance abuse, exacerbation of self-destructive behaviors, and promotion of poor partner choice in relationships [10, 11]. In this way, depression can be seen as a vector of HIV transmission. Thirdly, HIV increases the risk of developing major depression through a variety of mechanisms, including direct injury to sub-cortical areas of the brain, chronic stress, stigma, worsening social isolation, bereavement, debilitation, and intense demoralization [12]. An accumulating body of data now shows that depression may have an impact on morbidity and mortality among individuals with HIV disease. Although the specific physiologic mechanisms involved in this process have not been delineated, there is some evidence to suggest that depression reduces several in vitro measures of immune function including the killer lymphocytes such as CD8+ T lymphocytes and natural killer cells, and this may represent the key pathways through which depression affects HIV disease progression [13, 14]. Many studies have shown an increase in the prevalence rates of depression as CD4 count declines in patients with HIV/AIDS. The Multicenter AIDS Cohort
HIV PATIENTS’ DEPRESSION AND CD4 CELL COUNT /
255
Study showed a two-and-half-fold increase in rates of depression as patients CD4 cell count fall below 200 cells per mm3 [15]. Another study in Uganda found, after adjusting for age, gender, education, and source of income, that HIV patients with CD4 counts < 50 cells/mm3 were more likely to be depressed (odds ratio 2.34, 95% confidence interval, 1.39-3.93, P = 0.001) [16]. Some other studies, however, did not find this association [17, 18]. The purpose of this study is to determine the prevalence of current depressive disorder and its association with CD4 cell count in patients with HIV/AIDS attending an outpatient clinic in Northern Nigeria. This study will help create awareness among clinicians involved in the care of people living with HIV/AIDS about depression in HIV infection and its relevance to the immune status and disease progression. This will help to promote interventions that will enhance routine screening, early diagnosis, and treatment of depression in this group of patients. METHODOLOGY A descriptive cross-sectional study design was conducted at Virology outpatient clinic at the Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria. The hospital is a 1000-bed capacity tertiary health facility located in Shika, a predominantly Hausa speaking rural community. Although being the main tertiary health facility in Northwestern Nigeria, the population attending the hospital is largely cosmopolitan. Beginning with the first patient on the list of daily HIV clinic attendance, every consecutive patient who met eligibility criteria and gave informed consent was recruited and interviewed until the sample size of 310 participants was attained. This sample size was calculated using the formula for calculating minimum sample size in cross-sectional studies based on the assumption of prevalence rate of 38.7% for depression in patients with HIV from a previous study (19): n=
Z2 P q D2
(20)
The Ethics and Research Committee of the University Teaching Hospital approved the study protocol and duly signed informed consents were obtained from the participants after the aims and objectives of the study had been explained. Eligibility criteria included patients with confirmed HIV infection who were on antiretroviral medication; the study excluded patients receiving treatment for other co-morbid chronic medical conditions in their medical records, patients seeing a mental health professional for any other neuropsychiatric conditions besides depression, and those found to have marked cognitive impairment following a mental state examination. Participants found to have impaired memory and disorientation in person, place, or time were excluded from the study.
256 / OLISAH, ADEKEYE AND SHEIKH
Socio-demographic questionnaire was administered to all the qualifying participants. Each was screened for depressive symptoms using the Center for Epidemiologic Studies Depression Scale Revised (CES-DR) instrument. The CES-DR is an instrument used in epidemiological studies as a screening tool for depressive symptomatology. Participants with a CES-DR score ³ 16 were considered as having significant depressive symptoms and were then administered the depression module of the Schedule for Clinical Assessment in Neuropsychiatry (SCAN). The SCAN is a WHO structured diagnostic instrument used for assessing, measuring, and classifying the psychopathology and behavior associated with the major psychiatric disorders of adult life. The most recent documentation of participants’ CD4 cell count results from the hematology laboratory of the hospital was obtained from their medical records. All questionnaires were translated into Hausa language for patients with low education and interviewer administered by a single trained investigator over a 5-month period. SPSS-16 software was used for data entry and analysis. Chi-square test was used to characterize the significance of the association between depressive disorder and CD4 cell count while multiple regression analysis was used to test the value of CD4 cell count as a predictor for depressive disorder in the participants. All the participants completed the assessment. RESULTS A total of 310 patients with HIV participated in the study. The mean duration of their illness (i.e., time since HIV diagnosis) was 26.5 months (± 8.9), and mean duration on antiretroviral therapy (ART) was 17.7 months (± 5.2). The socio-demographic characteristics of participants showed that 31.6% were males, 52.9% were married, 38.7% were unemployed, mean age was 35.5 years ± 8.97, and 64.5% had at least a secondary education. See Table 1. The results show that 21.3% (n = 66) of the participants had significant depressive symptoms (i.e., CES-DR score >16). Also, 14.2% (n = 44) of the total met the diagnostic criteria for depressive disorder (based on the RDC). Kappa statistics between those identified as depressed through the CESD-DR and the ICD-10 criteria was 0.759, signifying good agreement. The CD4 cell counts of participants with depressive disorder were compared with those of participants without depressive disorder as shown in Table 2. A significant association was found between depression and low CD4 cell count (c2 = 30.257, df = 1, p < 0.05). Multiple regression was run to test predictors of depressive disorder based on gender, age, occupation, marital status, education, and CD4 count as shown in Table 3. These variables jointly and significantly predicted depression, F(6, 95) = 35.193, p < .05, R2 = 0.62. CD4 cell count significantly predicted depression (beta = 0.58, p < .05) accounting for 58%.
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Table 1. Socio-Demographic Characteristics of Participants Variable
n (%)
Sex Males (mean age 40.1 years ± 8.8) 98 (31.6) Females (mean age 33.4 years ± 8.2) 212 (68.4) Mean age overall: 35.5 years ± 8.97 Religion Islam Christianity
124 (40) 186 (60)
Marital status Single Married Divorced Widowed Separated
66 (21.3) 164 (52.9) 14 (4.5) 64 (20.6) 2 (0.6)
Occupation Unemployed Unskilled worker Petty trader Semi-skilled worker Highly skilled professional Retired
120 (38.7) 29 (9.4) 48 (15.5) 22 (7.1) 85 (27.4) 6 (1.9)
Education Primary school Secondary school Tertiary Arabic schooling No schooling
62 (20) 116 (37.4) 84 (27.1) 20 (6.5) 28 (9)
DISCUSSIONS Most of the patients with HIV in this study had had a relatively short illness and treatment duration (mean = 26.5 months and 17.7 months, respectively). This may be a reflection of the recent efforts in Nigeria by government and nongovernmental organizations and international agencies to promote voluntary counseling and testing, public education about HIV and AIDS, and free antiretroviral therapy for people who need it.
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Table 2. CD4 Count of Subjects With Depressive Disorder and Those Without Depressive Disorder Diagnosis Depressive disorder
No depressive disorder
0–150 cells/mm3
24 (54.5%)
60 (22.6%)
cells/mm3
20 (45.5%)
206 (77.4%)
>150
c2 = 30.257, df = 1, p £ 0.05.
Table 3. Socio-Demographic and CD4-Related Factors Associated with Depression: Multiple Regression Results Variable
Beta
Multiple R2
Adjusted R2
F ratio
p-Value
Age
0.04
0.62
0.61
35.193
.000
Gender
0.20
Marital status
0.15
Occupation
0.12
Education
0.02
CD4 count
0.58
F(6, 95) = 35.193, p < .05, R2 = 0.62.
The prevalence of depressive disorder in the participants was 14.2%. Other studies have likewise found increased prevalence of depression in people living with HIV/AIDS [3, 4]. However, the relatively lower prevalence for depressive disorder observed in this study compared to the 28.7% reported by Adewuya et al. [3] in Southern Nigeria or the 22 to 32% reported in some studies in the United States [4] may be due to the case ascertainment method used and the category of patients studied in terms of their stage of HIV disease. Studies have shown that increased prevalence of depressive disorder in people living with HIV may be due to the effects of the virus on the sub-cortical areas
HIV PATIENTS’ DEPRESSION AND CD4 CELL COUNT /
259
of the brain, chronic stress experienced by patients with HIV/AIDS resulting from unemployment, poor financial security, burden of care due to the disease, stigmatization, bereavement, and intense demoralization [12]. The study found a significant association between depressive illness and low CD4 cell count. Also, CD4 cell count was the most significant predictor for depression similar to findings in other studies [15, 16]. This may be due to the negative effects of depression on immune status which may consequently result in HIV disease progression [13, 14]. The study suggests that depression is common in people living with HIV/AIDS in Nigeria and is associated with declining CD4 cell count with serious consequences on disease progression. Unfortunately, mental health services are provided by few tertiary health centers scattered around the country which is grossly inadequate for the teaming population. Again, mental health integration in primary healthcare in Nigeria is rudimentary and most HIV response in the country has excluded mental health aspects. Studies have shown that significant numbers of HIV-infected people have, or develop, mental health problems, and this often adversely impacts on HIV/AIDS treatment. A more prominent role is needed for mental health interventions in global HIV/AIDS initiatives. Integrating psychiatric and psychosocial interventions should benefit both the mental and the physical health of people living with HIV/AIDS. Therefore, physicians involved in the care of people with HIV or AIDS should routinely assess their patients for psychiatric morbidity, especially depression using simple screening instruments, so as to facilitate appropriate and holistic care. This study was limited by the fact that it is hospital-based and the results may not be generalized to the entire population of PLHIV. Secondly, the authors did not control for the somatic items in the CES-D and this might have confounded the measure of depression. Also, the categorization of CD4 cell counts (a continuous variable) during data analysis may give a slightly biased result.
REFERENCES 1. UNAIDS Global report. UNAIDS Report on Global AIDS Epidemic, 2012. 2. Federal Republic of Nigeria. Global AIDS Response Country Progress Report, Nigeria, 2012. 3. Adewuya AO, Afolabi MO, Ola BA, Ogundele OA, Ajibare AO, Oladipo BF, Fakande I. Relationship between depression and quality of life in persons with HIV infection in Nigeria. International Journal of Psychiatry in Medicine 2008;38(1): 43-51. 4. Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London SA, Turner BJ, Eggan F, Beckman R, Vitiello B, Morton SC, Orlando M, Bozzette SA, Ortiz-Barron L, Shapiro M. The estimated prevalence of psychiatric disorders, drug use and dependence among people with HIV disease in the United States. Archives of General Psychiatry 2001;58:721-728.
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