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African Journal of AIDS Research 2011, 10(3): 247–254 Printed in South Africa — All rights reserved
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.626294
Depression underdiagnosis and the effects on quality of life in outpatients with HIV at a Nigerian university teaching hospital Victor Obiajulu Olisah1*, Olusegun Baiyewu2 and Taiwo Lateef Sheikh1 1
Ahmadu Bello University Teaching Hospital, Department of Psychiatry, PMB 06, Zaria, Kaduna State, Nigeria University College Hospital, Department of Psychiatry, PO Box 5116, Ibadan, Nigeria *Corresponding author, e-mail: [email protected] 2
The study aimed to determine the frequency of depressive disorder in a sample of patients with HIV and its level of underdiagnosis by attending physicians. The study also explored the effect of depressive disorder on the quality of life (QOL) of patients with HIV. A sociodemographic questionnaire was administered to patients with HIV attending a medical out-patient clinic at Ahmadu Bello University Teaching Hospital, central northern Nigeria. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to screen for depressive symptoms, and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) was used to confirm the diagnosis of depressive disorder. The patients’ medical records were screened for documentation of depressive symptoms or previous treatment with antidepressants by an attending physician. The World Health Organization Quality of Life assessment short version (WHOQOL-BREF) was used to measure six domains of QOL. A total of 310 patients with HIV participated in the study; of these, 14.2% (n = 44) met the diagnostic criteria for depressive disorder, according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). All of these cases of depressive disorder had not been previously recognised by any attending physician. Of the 310 participants, 58 (18.7%) had a ‘poor’ score and 252 (81.3%) had an ‘average or above’ score for overall QOL. Of the 44 with depressive disorder, 28 (63.6%) were among those with a poor score for overall QOL. A fairly similar pattern was observed for all the other domains, with patients with depressive disorder accounting for greater proportions of the participants with poor domain scores. Thus, the authors found that depression is common but seldom clinically recognised in people with HIV, and that it is associated with a reduction in quality of life. Identifying and treating depression in patients with HIV will improve functioning and general wellbeing. Keywords: Africa, depressive disorder, mental health, outpatients, prevalence, primary healthcare, psychological aspects, surveys, symptoms
Introduction HIV/AIDS statistics in Nigeria Nigeria has the third-largest population of people living with HIV or AIDS (PLHIV), after South Africa and India. National HIV seroprevalence increased from 1.8% in 1991 to 5.8% in 2001, with only a modest drop to 4.4% in 2005 (Federal Ministry of Health, 2006). It is now estimated that 3.6% of Nigeria’s population of approximately 150 million are living with HIV (National Agency for the Control of AIDS, 2010). HIV/AIDS treatment and care in Nigeria Resources needed to provide sufficient treatment and care for those living with HIV in Nigeria are seriously lacking. A study of healthcare providers found that many had not received sufficient training on HIV prevention and treatment and many health facilities had a shortage of medications, equipment and materials (Physicians for Human Rights, 2006). Despite an increase in major HIV/ AIDS initiatives at the national level, many shortcomings and barriers remain in terms of provision of and access to HIV-related services. In 2007, only 26% of those in
need of antiretroviral treatment (ART) were receiving it — a situation that has not changed much to date (UNAIDS, 2008). Also, only a small number of HIV/AIDS-treatment programmes in Nigeria provide mental health services and only a fraction of the people with HIV receive the mental health care they need. Healthcare delivery in Nigeria Nigeria is generally short of physicians and has about 130 psychiatrists, despite a population of more than 150 million (Nigeria Health Watch, 2009). Most general practitioners are without postgraduate training and are located in private practices, in most cases working on their own. This group of physicians, along with others in government-owned institutions (i.e. general hospitals and teaching hospitals), offer primary care services. Unfortunately, these services are mainly located in urban areas — thus most rural areas, where approximately 70% of the populace resides, are deprived of health services. As part of the government’s efforts to fix this problem, between five and 15 local health facilities have been established in each local government area (district) of the country. Specially trained individuals
African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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with or without a medical background and with different educational levels run these facilities. In Nigeria, the emphasis of primary care has been mostly geared to maternal and child healthcare, and, occasionally, the treatment of minor physical ailments and infectious diseases. Odejide, Morakinyo, Oshiname, Omigbodun, Ajuwon & Kola (2002) found that primary healthcare workers had very poor knowledge of mental disorders and virtually no mental health services were provided at the primary healthcare facilities studied. The sparse mental health services offered through private general practices and government-owned hospitals seem to be the only hope for the majority of the public. Judging by the level of mental health training received by primary healthcare workers (mainly from undergraduate schools), combined with deep-seated negative attitudes and superstitious beliefs about mental disorders, the mental health services offered to the populace at the primary care level is certainly minimal. Also, the roles of traditional and religious healers in Nigeria cannot be ignored. Though orthodox psychiatric practice has expanded considerably in recent times, it is well documented that the majority of psychiatric patients still primarily seek help from traditional healers and churches (Gurege & Lasebikan, 2006). Significant numbers of HIV-infected people have, or develop, mental health problems, and this often adversely impacts on HIV/AIDS treatment and adherence. 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 (Freeman, Patel, Collins & Bertolote, 2005). Statistics on depression in the general population Depression is the fourth leading cause of disease burden, accounting for 4.4% of total disability-adjusted life years (DALYs) globally in the year 2000, and it causes the largest amount of non-fatal disease burden in the world, accounting for almost 12% of total years lived with disability worldwide (Üstün, Ayuso-Mateos, Chatterji, Mathers & Murray, 2004). Depression is a serious psychiatric condition that affects an individual’s mood, causing significant distress and impairment in their level of functioning. Figures for depression prevalence in the general population have varied substantially between surveys. Regier, Narrow, Rae, Manderscheid, Locke & Goodwin (1993) found a lifetime prevalence of 5% for major depression in the United States’ population. The prevalence of depression in the Danish general population is 3–4% (Olsen, Munk-Jorgensen & Bech, 2007). Gureje, Lasebikan, Kola & Makanjuola (2006) found 3.3% lifetime prevalence of major depression in a Nigerian survey; they also pointed out that although available therapies alleviate depression symptoms in over 80% of those treated, in Nigeria less than 1% ever present to a specialist for treatment. Statistics on depression in HIV/AIDS clinic populations Depression prevalence in clinic populations of HIV patients in the United States has been found to range from 22% to 32% (Bing, Burnam, Longshore, Fleishman, Sherbourne, London et al., 2001). In general, depression is the most
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commonly observed psychiatric disorder among patients with HIV (HIV Clinical Resource, 2010). One study in Nigeria found 28.7% prevalence of depression in patients with HIV or AIDS (Adewuya, Afolabi, Ola, Ogundele, Ajibare, Oladipo & Fakande, 2008). A meta-analysis of data from 10 studies examining the prevalence of depression among HIV-infected individuals revealed a two-fold increase in the prevalence of depression as compared with HIV-negative individuals (Ciesla & Roberts, 2001). A study of recently diagnosed HIV patients attending an outpatient clinic for infectious diseases at a teaching hospital in South Africa found 38.7% prevalence of depressive disorder (Olley, Gxamza, Seedat, Stein & Reuter, 2003). Petrushkin, Boardman & Ovuga (2005) found 54.3% prevalence of depressive disorder in patients with HIV attending the HIV/AIDS support organisation clinic at Mulago Hospital in Kampala, Uganda, and Morrison, Petitto, Ten Have, Gettes, Chiappini, Webber et al. (2002) found 19.4% prevalence in HIV-positive women recruited from outpatient medical clinics, country health departments and organisations focusing on HIV care in north-central Florida. Underdiagnosis of depression in patients with HIV Current estimates may represent an underestimation as there is evidence that depression may be under diagnosed in the context of HIV-related medical care (Steven, Kilbourne, Gifford, Burnam, Turner, Shapiro et al., 2003). Despite the enormous advances in brain research in the past 20 years, depression often goes undiagnosed and untreated. Although as many as one in three persons with HIV may suffer from depression (Bing et al., 2001), the warning signs of depression are often misinterpreted as an inevitable reaction to being diagnosed with HIV or as a result of symptoms of HIV disease. In Nigeria, some researchers found poor recognition of minor psychiatric conditions by general practitioners (Adeyemi & Jegede, 1999). Depression is a separate illness that can and should be diagnosed and treated in people undergoing treatment for HIV or AIDS. In a study in the United States, Steven et al. (2003) interviewed patients using the Composite International Diagnostic Interview (CIDI) and reviewed their medical records for the previous 2½ years. The researchers defined ‘depression underdiagnosis’ as a diagnosis of major depressive disorder based on the CIDI results and no record of depression diagnosis by a principal healthcare provider. Of 1 140 patients, 37% had CIDI-defined major depression, and 45% of these did not have a documented diagnosis of depression in their medical records. The researchers concluded that practitioners should be more attentive to diagnosing comorbid depression in HIV-infected patients. The problem may be worse in Africa; in a study of psychiatric disorders in HIV-positive individuals in urban Uganda, Petrushkin et al. (2005) found 82.6% total prevalence of psychiatric disorders, while no individual had been assessed for comorbid psychiatric conditions by their physician or were receiving mental health treatment. Research has shown that depression in PLHIV may reduce adherence to ARVs (Cook, 2002; Murray, Semrau, McCurley, Thea, Scott, Mwiya et al., 2009), accelerate progression to AIDS illness (Lesserman, Jackson, Petitto,
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Golden, Silva, Perkins et al., 1999), and further diminish quality of life (Cook, 2002). Effects of depression on quality of life of HIV patients With improved treatments and longer survival times for persons with HIV infection, the maintenance and improvement of their functioning and wellbeing (collectively referred to as ‘health-related quality of life’) have become major goals of treatment. Research has shown that depression in HIV-infected people is responsible for additional illness burden and further reduction in quality of life (Cook, 2002). The World Health Organization (WHO) defined quality of life (QOL) as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns; it is a broad-ranging concept, with QOL complexly affected by the person’s physical health, psychological state, level of independence, social relationships, and relationship to salient features of their environment (The WHOQOL Group, 1995). QOL is important for measuring the impact of chronic diseases (Patrick & Erickson, 1993), and it correlates well with a patient’s functional capacity and wellbeing. We know from studies of patients and general populations that mood disorders, particularly depression, have a substantial negative impact on a person’s health-related QOL (Jia, Uphold, Wu, Reid, Findley & Duncan, 2004). In fact, for most domains of functioning and wellbeing, depression is more debilitating than most medical conditions. A study in Nigeria of the relationship between depression and QOL in persons with HIV found that a diagnosis of depression was significantly correlated with poorer QOL in all domains, except for the social-relationship domain (Adewuya et al., 2008); in addition, lower educational level, poor social support, and the presence of medical problems were associated with poorer QOL. In a study to assess the impact of psychiatric conditions on health-related QOL, a national probability sample of persons with HIV receiving medical care in the United States was recruited (Sherbourne, Hays, Fleishman, Vitiello, Magruder, Bing et al., 2000). The participants were screened for psychiatric conditions with CIDI, and health-related QOL was rated with a 28-item instrument: 36% screened positive for a current depressive disorder and 26% for dysthymia. Moreover, the participants with a probable diagnosis of any mood disorder had significantly worse functioning and wellbeing than those without a mood disorder diagnosis on all health-related QOL measures, including the physical health and mental health composites (Sherbourne et al., 2000). These findings substantiate the considerable additional illness burden associated with mood disorders in HIV-infected people. A study in South Africa compared QOL in HIV-seropositive and HIV-seronegative patients and found poorer QOL in the seropositive patients (Hughes, Jelsma, Maclean, Darder & Tinise, 2004). Furthermore, depression, anxiety, and physical symptoms of pain or discomfort were significantly associated with poor QOL (Hughes et al., 2004). A study in the United States found lower QOL among participants with depressive disorder who were also receiving highly active antiretroviral treatment (HAART) (Liu, Johnson, Ostrow,
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Silvestre, Visscher & Jacobson, 2006). Another study in Taiwan similarly found that identifying and treating depression in patients with HIV or AIDS improved QOL (Yen, Tsai, Lu, Chen, Chen, Chen & Chen, 2004). In contrast, a study in Senegal assessed QOL in HIV patients receiving either an efavirenz-based or protease-inhibitor-based ARV drug and found 18% prevalence of depression and good scores for QOL (Poupard, Ngom Gueye, Thiam, Ndiaye, Girard, Delaporte et al., 2007); however, the researchers concluded that it is still important to monitor depression and QOL in the follow-up of HIV-infected patients. Management of psychiatric disorders in PLHIV The assessment and treatment of psychiatric disorders in PLHIV requires taking a comprehensive history from the patient and/or caregiver. This should especially focus on the history of the current complaint, past psychiatric history, past and present substance abuse, full medical history, a history of sexual-risk behaviour, and history of the patient’s adherence to previous HIV treatment regimens. Of equal importance is the identification of social support systems. A mental status examination (MSE) of the patient’s level of cognitive (knowledge-related) ability, appearance, emotional mood, and thought patterns at the time of the evaluation should also be conducted. In the psychotic patient one needs to focus specifically on the behaviour and appearance of the patient. His or her speech and speed of thoughts should be assessed, and mood symptoms, affect, suicidality and neuro-vegetative symptoms must be evaluated. Finally, perceptual disturbances, thought form, thought content, and insight and judgment also need to be assessed. A comprehensive and meticulous physical and neurological examination should be performed to exclude any organic causes for the presenting psychiatric symptoms. One should first examine for signs of delirium and rule out HIV-associated cognitive disorders. Medical diagnoses should be considered first, and only after that should a psychiatric diagnosis be entertained. A differential diagnosis needs to consider the presence of a pre-existing psychiatric illness, use of illicit substances, or the presence of cognitive impairment. The assessment and treatment of psychotic disorders in PLHIV can be very challenging. A useful delineation may be to divide psychosis in PLHIV into: 1) psychiatric disorders predating the HIV infection; 2) new-onset psychotic disorders; and, 3) disorders associated with medical conditions (e.g. delirium) or substance intoxication or withdrawal, as well as those that are likely to be complications of treatment (e.g. ARVs or anti-tuberculosis drugs). A good overall history, assessment of mental state, and a physical examination are usually important in making this delineation. Laboratory investigations are crucial in the assessment of delirium and substance intoxication. The choice of antipsychotic drugs depends largely on the patient, the presenting symptoms, the patient’s past response, a profile of potential side-effects, possible drug interactions, cost, and the pill burden for the chronically ill patient. Many patients with new-onset psychosis or psychosis associated with various medical conditions may only require short-term treatment with antipsychotic
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medication. However, some patients may require long-term maintenance/treatment with antipsychotic agents — here, special attention must be paid to the following factors: the typical antipsychotics are commonly used in resourceconstrained settings (e.g. low doses of haloperidol or chlorpromazine can be used); vigilance is required with regard to extrapyramidal side-effects; and newer atypical antipsychotics, such as risperidone or olanzepine, are now widely used in the treatment of psychotic disorders in HIV/ AIDS, with a lower propensity to cause extrapyramidal side-effects. The impact of depression on the course of the HIV infection has sometimes necessitated specific psychosocial and pharmacologic treatments targeting individuals with comorbid depression and HIV. Pharmacotherapy is the mainstay of treatment of moderate to severe depression. Several studies have demonstrated the efficacy of various antidepressant agents in HIV patients, but no single antidepressant has been found to be superior for treating HIV-infected patients on the whole (Olatunji, Mimiaga, O’Cleirigh & Safren, 2006). Aside from how well the pharmacology of the antidepressant matches a patient’s disease, the engine that drives effectiveness is the patient’s adherence. The general rule is to start at low doses of any medication and titrate up to a therapeutic dose slowly, so as to minimise early side-effects that may act as obstacles to adherence. Patients who show a partial response to an antidepressant drug (after adequate dosage and duration) should be offered an augmentation strategy. The choice of an antidepressant is largely based on the side-effects profile. Antidepressant drugs that are useful in treating depression in patients with HIV include amitriptyline, imipramine, clomipramine, fluoxetine, paroxetine, sertraline, fluvoxamine and venlafaxine (Elliot & Roy-Byrne, 1998). The use of psychostimulants, such as methylphenidate and dextroamphetamine, has also been found effective (Wagner & Rabkin, 2000). Clinicians often wonder about the interaction of antidepressants and HAART. Some interactions may occur but two points deserve emphasis: first, because depression is associated with reduction in adherence to HAART, untreated depression may be equally or more detrimental to HIV-disease progression than any medication interaction; second, experience in working with comorbid depression and HIV has not shown clinical significance of antidepressant/HAART interaction. Psychosocial intervention is an integral part of treatment for depression in patients with HIV. The combination of psychosocial intervention and medication was shown to be more effective for patients than either modality alone. Among the individual psychotherapies, interpersonal psychotherapy, cognitive-behavioural psychotherapy and supportive psychotherapy are effective in the treatment of depression in patients with HIV (Markowitz, Klerman, Clougherty, Spielman, Jocobsberg, Fishman et al., 1995). A social intervention, such as social-support group therapy, is also effective. Identifying and treating depression in patients with HIV could result in substantial improvement in their quality of life and potentially increase their medication adherence, which in turn would affect illness severity and progression.
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The treatment of anxiety disorders in cases of HIV or AIDS also requires a combination of psychosocial intervention and medication. Adequate counselling and relaxation techniques are sufficient to treat mild anxiety associated with the various crisis points in the course of HIV disease. For more severe anxiety disorders, antidepressants and cognitive behavioural techniques are useful. Every patient with HIV or AIDS presenting with a psychiatric disorder must also be assessed for suicidal risk, and in cases where the risk is high, the patient should be hospitalised for detailed evaluation and appropriate treatment. Substance abuse is a common problem in persons with HIV (Winstanley, Gust & Strathdee, 2006), hence physicians should exercise suspicion while assessing patients. When present, motivational interviews are important. Patients with severe problems, and who are motivated, should be hospitalised for detoxification and appropriate pharmacological and psychosocial treatment. Aims of the study Despite the fact that about 3.6% of Nigerians are living with HIV, there are no studies on depression and quality-of-life issues in this group in the northern part of the country. Thus, this study aimed to determine the frequency of depressive disorder in a sample of Nigerian patients with HIV and to determine to what extent the sample of HIV patients had ever been diagnosed or treated for depressive disorder by an attending physician. The study also sought to determine the impact of depression on the quality of life of patients with HIV in northern Nigeria. Methods The participants were made up of a consecutive sample of 310 patients with HIV attending the virology clinic at Ahmadu Bello University Teaching Hospital in Zaria, Nigeria, during September to December 2006, and who also gave informed consent and met the study’s inclusion criteria. Eligibility criteria included patients with confirmed HIV infection who were on ARV medication; the study excluded patients known to have other comorbid chronic medical conditions, patients known to have other psychiatric conditions besides depression, and those found to have marked cognitive impairment. To determine whether patients were not eligible on the grounds of marked cognitive impairment, all the potential participants were initially screened for cognitive impairment, by a single investigator carrying out a mental state examination. Thus, the patients were assessed for recent memory, remote memory, and orientation in person, place and time. Those found to have impaired memory and/or disorientation in person, place, or time were excluded from the study. Ethical clearance for the study was obtained from the hospital’s research and ethics committee. A sociodemographic 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. Those with a CES-DR score 16 were considered as having significant depressive symptoms and were then administered the relevant sections of the Schedule
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for Clinical Assessment in Neuropsychiatry (SCAN). Thirty participants (about 10% of the sample size) who fell slightly short of attaining the CES-DR cut-off score of 16 were randomly selected and also administered the SCAN. The Research Diagnostic Criteria (RDC) of the International Classification of Diseases (ICD-10) (see World Health Organization, 1993) was used to generate a clinical diagnosis of depressive disorder based on any depressive symptoms noted by way of the SCAN. The medical records of all participants (from the previous six months) were screened for documentation of depressive symptoms or treatment with antidepressants by an attending physician. ‘Underdiagnosis of depression’ was defined as a SCAN diagnosis of depression without any documentation of depression in the participant’s medical record. Next, the WHOQOL-BREF questionnaire was administered to the participants. The participants’ quality of life (QOL) in all domains of was categorised as ‘poor,’ ‘average’ or ‘good.’ The domain for overall QOL and health satisfaction were categorised subjectively by the participants, while domains 1 through 4 were categorised by the authors on the basis of the domain mean score (±1 standard deviation [SD]). Domain scores 1 SD from the domain mean were categorised as ‘good’; and domain scores between 1 SD below and above the domain mean were categorised as ‘average.’ SPSS-12 software was used for entering and analysing the data. A chi-square test was used to characterise the significance of the difference between QOL in depressed HIV/AIDS patients compared to non-depressed HIV/AIDS patients. 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 ART was 17.7 months (±5.2). The participants’ sociodemographic characteristics are presented in Table 1. The results show that 21.3% (n = 66) of the participants had significant depressive symptoms (i.e. CES-DR score >16) while 78.7% (n = 244) had no significant depressive symptoms (i.e. CES-DR score 0.05).
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The QOL categorisations for the participants with depressive disorder were compared with those for participants without depressive disorder (see Table 2). During the data analysis we merged the ‘average’ and ‘good’ categories of QOL in all domains to generate the single ‘average or above’ category because some cells in the resulting table of QOL categorisation (for both the participants with and those without depressive disorder) had small values ( 0.05 (domain mean score = 62.99, SD = 9.28)
psychiatric morbidity, especially depression, so as to enhance appropriate care and improve treatment outcomes. Simple screening instruments for psychiatric conditions should be provided in all HIV/AIDS treatment centres so as to improve case identification. Consultation-liaison psychiatry services should be routinely extended to patients receiving treatment for HIV or AIDS. Again, mental health must be integrated into primary healthcare and global HIV/ AIDS initiatives. Nigerian universities should allocate more time to psychiatry training in their curriculum so as to better equip medical students with the knowledge required to face challenges relating to psychiatry as doctors. There are some limitations to this study. Participants who were asked to recall and rate QOL issues may give incorrect answers due to problems with memory. Because the study was hospital-based, the results may not be generalised to the entire population of PLHIV; however, the findings provide insight to those who approach medical facilities for treatment. The authors did not remove the somatic items in the CES-D and this might have confounded the measure of depression. Lastly, the study did not take into consideration the participants’ stage of HIV disease (e.g. CD4 cell count) in relation to depression, which may be relevant and thus an important area for future research. Acknowledgments — We are grateful to colleagues in the Department of Psychiatry at Ahmadu Bello University Teaching Hospital, and to the doctors and nursing staff at the virology clinic for their assistance during the period of data collection.
No depressive disorder (n = 266) n (%)
Total (n = 310) n (%)
28 (63.6) 16 (36.4)
30 (11.3) 236 (88.7)
58 (18.7) 252 (81.3)
36 (81.8) 8 (18.2)
68 (25.6) 198 (74.4)
104 (33.5) 206 (66.5)
20 (45.5) 24 (54.5)
24 (9) 242 (91)
44 (14.2) 266 (85.8)
28 (63.6) 16 (36.4)
12 (4.5) 254 (95.5)
40 (12.9) 270 (87.1)
28 (63.6) 16 (36.4)
48 (18.1) 218 (81.9)
76 (24.5) 234 (75.5)
4 (9.1) 40 (90.9)
10 (3.8) 256 (96.2)
14 (4.5) 296 (95.5)
The authors — Victor Obiajulu Olisah (MBBS, FWACP Psych) is a consultant psychiatrist and lecturer in the Department of Psychiatry at Ahmadu Bello University. Olusegun Baiyewu (MBBS, FWACP Psych, FMC Psych) is a consultant psychiatrist and professor in the Department of Psychiatry at University College Hospital in Ibadan. Taiwo Lateef Sheikh (MSc, MBBS, FWACP Psych) is a consultant psychiatrist and senior lecturer in the Department of Psychiatry at Ahmadu Bello University.
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802–809. Olatunji, B.O., Mimiaga, M.J., O’Cleirigh, C. & Safren, S.A. (2006) Review of treatment studies of depression in HIV. Source Topics in HIV Medicine 14(3), pp. 112–124. Olley, B.O., Gxamza, F., Seedat, S., Stein, D.J. & Reuter, H. (2003) Psychiatric morbidity in recently diagnosed HIV patients in South Africa: a preliminary report. AIDS Bulletin 12(1), pp. 9–10. Olsen, L.R., Munk-Jorgensen, P. & Bech, P. (2007) The prevalence of depression in Denmark. Research Gate 169(16), pp. 1425–1426. Patrick, D.L. & Erickson, P. (1993) Health Status and Health Policy: Quality of Life in Health Care Evaluation and Resource Allocation. New York, Oxford University Press. Petrushkin, H., Boardman, J. & Ovuga, E. (2005) Psychiatric disorders in HIV-positive individuals in urban Uganda. The Psychiatrist 29, pp. 455–458. Physicians for Human Rights (2006) ‘Nigeria: Access to health care for people living with HIV and AIDS.’ Online at: . Poupard, M., Ngom Gueye, N.F., Thiam, D., Ndiaye, B., Girard, P.M., Delaporte, E., Sow, P.S. & Landman, R. (2007) Quality of life and depression among HIV-infected patients receiving efavirenz- or protease-inhibitor-based therapy in Senegal. HIV Medicine 8(2), pp. 92–95. Regier, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z. & Goodwin, F.K. (1993) The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 50(2), pp. 85–94. Sherbourne, C.D., Hays, R.D., Fleishman, J.A., Vitiello, B., Magruder, K.M., Bing, E.G., McCaffrey, D., Burnam, A., Longshore, D., Eggan, F., Bozzette, S.A. & Shapiro, M.F. (2000) Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. The American Journal of Psychiatry 157(2), pp. 248–254. Steven, M.A., Kilbourne, A.M., Gifford, A.L., Turner, B., Shapiro, M.F. & Bozzette, S.A. (2003) Underdiagnosis of depression in HIV. Journal of General Internal Medicine 18(6), pp. 450–460. The WHOQOL Group (1995) The World Health Organization quality of life assessment (WHOQOL): position paper from the World Health Organization. Social Science and Medicine 41(10), pp. 1403–1409. UNAIDS (2008) Report on the Global AIDS Epidemic. Geneva, UNAIDS. Üstün, T.B., Ayuso-Mateos, J.L., Chatterji, S., Mathers, C. & Murray, C.J.L. (2004) Global burden of depressive disorders in the year 2000. The British Journal of Psychiatry 184, pp. 386–392. Wagner, G. & Rabkin, R. (2000) Effects of dextroamphetamine on depression and fatigue in men with HIV: a double-blind, placebocontrolled trial. Journal of Clinical Psychiatry 61(6), pp. 436–440. Winstanley, E.L, Gust, S.W & Strathdee, S.A. (2006) Drug abuse and HIV/AIDS: international research lessons and imperatives. Drug Alcohol Dependence 82(1), pp. 81–85. World Health Organization (WHO) (1993) International Classification of Diseases — Diagnostic Criteria for Research (10th edition). Geneva, WHO. Yen, C.F., Tsai, J.J., Lu, P.L., Chen, Y.H., Chen, T.C., Chen, P.P. & Chen, T.P. (2004) Quality of life and its correlates in HIV/AIDS male outpatients receiving highly active antiretroviral therapy in Taiwan. Psychiatry and Clinical Neurosciences 58(5), pp. 501–506.
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African Journal of AIDS Research 2011, 10(3): 247–254 Printed in South Africa — All rights reserved
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.626294
Depression underdiagnosis and the effects on quality of life in outpatients with HIV at a Nigerian university teaching hospital Victor Obiajulu Olisah1*, Olusegun Baiyewu2 and Taiwo Lateef Sheikh1 1
Ahmadu Bello University Teaching Hospital, Department of Psychiatry, PMB 06, Zaria, Kaduna State, Nigeria University College Hospital, Department of Psychiatry, PO Box 5116, Ibadan, Nigeria *Corresponding author, e-mail: [email protected] 2
The study aimed to determine the frequency of depressive disorder in a sample of patients with HIV and its level of underdiagnosis by attending physicians. The study also explored the effect of depressive disorder on the quality of life (QOL) of patients with HIV. A sociodemographic questionnaire was administered to patients with HIV attending a medical out-patient clinic at Ahmadu Bello University Teaching Hospital, central northern Nigeria. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to screen for depressive symptoms, and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) was used to confirm the diagnosis of depressive disorder. The patients’ medical records were screened for documentation of depressive symptoms or previous treatment with antidepressants by an attending physician. The World Health Organization Quality of Life assessment short version (WHOQOL-BREF) was used to measure six domains of QOL. A total of 310 patients with HIV participated in the study; of these, 14.2% (n = 44) met the diagnostic criteria for depressive disorder, according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). All of these cases of depressive disorder had not been previously recognised by any attending physician. Of the 310 participants, 58 (18.7%) had a ‘poor’ score and 252 (81.3%) had an ‘average or above’ score for overall QOL. Of the 44 with depressive disorder, 28 (63.6%) were among those with a poor score for overall QOL. A fairly similar pattern was observed for all the other domains, with patients with depressive disorder accounting for greater proportions of the participants with poor domain scores. Thus, the authors found that depression is common but seldom clinically recognised in people with HIV, and that it is associated with a reduction in quality of life. Identifying and treating depression in patients with HIV will improve functioning and general wellbeing. Keywords: Africa, depressive disorder, mental health, outpatients, prevalence, primary healthcare, psychological aspects, surveys, symptoms
Introduction HIV/AIDS statistics in Nigeria Nigeria has the third-largest population of people living with HIV or AIDS (PLHIV), after South Africa and India. National HIV seroprevalence increased from 1.8% in 1991 to 5.8% in 2001, with only a modest drop to 4.4% in 2005 (Federal Ministry of Health, 2006). It is now estimated that 3.6% of Nigeria’s population of approximately 150 million are living with HIV (National Agency for the Control of AIDS, 2010). HIV/AIDS treatment and care in Nigeria Resources needed to provide sufficient treatment and care for those living with HIV in Nigeria are seriously lacking. A study of healthcare providers found that many had not received sufficient training on HIV prevention and treatment and many health facilities had a shortage of medications, equipment and materials (Physicians for Human Rights, 2006). Despite an increase in major HIV/ AIDS initiatives at the national level, many shortcomings and barriers remain in terms of provision of and access to HIV-related services. In 2007, only 26% of those in
need of antiretroviral treatment (ART) were receiving it — a situation that has not changed much to date (UNAIDS, 2008). Also, only a small number of HIV/AIDS-treatment programmes in Nigeria provide mental health services and only a fraction of the people with HIV receive the mental health care they need. Healthcare delivery in Nigeria Nigeria is generally short of physicians and has about 130 psychiatrists, despite a population of more than 150 million (Nigeria Health Watch, 2009). Most general practitioners are without postgraduate training and are located in private practices, in most cases working on their own. This group of physicians, along with others in government-owned institutions (i.e. general hospitals and teaching hospitals), offer primary care services. Unfortunately, these services are mainly located in urban areas — thus most rural areas, where approximately 70% of the populace resides, are deprived of health services. As part of the government’s efforts to fix this problem, between five and 15 local health facilities have been established in each local government area (district) of the country. Specially trained individuals
African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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with or without a medical background and with different educational levels run these facilities. In Nigeria, the emphasis of primary care has been mostly geared to maternal and child healthcare, and, occasionally, the treatment of minor physical ailments and infectious diseases. Odejide, Morakinyo, Oshiname, Omigbodun, Ajuwon & Kola (2002) found that primary healthcare workers had very poor knowledge of mental disorders and virtually no mental health services were provided at the primary healthcare facilities studied. The sparse mental health services offered through private general practices and government-owned hospitals seem to be the only hope for the majority of the public. Judging by the level of mental health training received by primary healthcare workers (mainly from undergraduate schools), combined with deep-seated negative attitudes and superstitious beliefs about mental disorders, the mental health services offered to the populace at the primary care level is certainly minimal. Also, the roles of traditional and religious healers in Nigeria cannot be ignored. Though orthodox psychiatric practice has expanded considerably in recent times, it is well documented that the majority of psychiatric patients still primarily seek help from traditional healers and churches (Gurege & Lasebikan, 2006). Significant numbers of HIV-infected people have, or develop, mental health problems, and this often adversely impacts on HIV/AIDS treatment and adherence. 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 (Freeman, Patel, Collins & Bertolote, 2005). Statistics on depression in the general population Depression is the fourth leading cause of disease burden, accounting for 4.4% of total disability-adjusted life years (DALYs) globally in the year 2000, and it causes the largest amount of non-fatal disease burden in the world, accounting for almost 12% of total years lived with disability worldwide (Üstün, Ayuso-Mateos, Chatterji, Mathers & Murray, 2004). Depression is a serious psychiatric condition that affects an individual’s mood, causing significant distress and impairment in their level of functioning. Figures for depression prevalence in the general population have varied substantially between surveys. Regier, Narrow, Rae, Manderscheid, Locke & Goodwin (1993) found a lifetime prevalence of 5% for major depression in the United States’ population. The prevalence of depression in the Danish general population is 3–4% (Olsen, Munk-Jorgensen & Bech, 2007). Gureje, Lasebikan, Kola & Makanjuola (2006) found 3.3% lifetime prevalence of major depression in a Nigerian survey; they also pointed out that although available therapies alleviate depression symptoms in over 80% of those treated, in Nigeria less than 1% ever present to a specialist for treatment. Statistics on depression in HIV/AIDS clinic populations Depression prevalence in clinic populations of HIV patients in the United States has been found to range from 22% to 32% (Bing, Burnam, Longshore, Fleishman, Sherbourne, London et al., 2001). In general, depression is the most
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commonly observed psychiatric disorder among patients with HIV (HIV Clinical Resource, 2010). One study in Nigeria found 28.7% prevalence of depression in patients with HIV or AIDS (Adewuya, Afolabi, Ola, Ogundele, Ajibare, Oladipo & Fakande, 2008). A meta-analysis of data from 10 studies examining the prevalence of depression among HIV-infected individuals revealed a two-fold increase in the prevalence of depression as compared with HIV-negative individuals (Ciesla & Roberts, 2001). A study of recently diagnosed HIV patients attending an outpatient clinic for infectious diseases at a teaching hospital in South Africa found 38.7% prevalence of depressive disorder (Olley, Gxamza, Seedat, Stein & Reuter, 2003). Petrushkin, Boardman & Ovuga (2005) found 54.3% prevalence of depressive disorder in patients with HIV attending the HIV/AIDS support organisation clinic at Mulago Hospital in Kampala, Uganda, and Morrison, Petitto, Ten Have, Gettes, Chiappini, Webber et al. (2002) found 19.4% prevalence in HIV-positive women recruited from outpatient medical clinics, country health departments and organisations focusing on HIV care in north-central Florida. Underdiagnosis of depression in patients with HIV Current estimates may represent an underestimation as there is evidence that depression may be under diagnosed in the context of HIV-related medical care (Steven, Kilbourne, Gifford, Burnam, Turner, Shapiro et al., 2003). Despite the enormous advances in brain research in the past 20 years, depression often goes undiagnosed and untreated. Although as many as one in three persons with HIV may suffer from depression (Bing et al., 2001), the warning signs of depression are often misinterpreted as an inevitable reaction to being diagnosed with HIV or as a result of symptoms of HIV disease. In Nigeria, some researchers found poor recognition of minor psychiatric conditions by general practitioners (Adeyemi & Jegede, 1999). Depression is a separate illness that can and should be diagnosed and treated in people undergoing treatment for HIV or AIDS. In a study in the United States, Steven et al. (2003) interviewed patients using the Composite International Diagnostic Interview (CIDI) and reviewed their medical records for the previous 2½ years. The researchers defined ‘depression underdiagnosis’ as a diagnosis of major depressive disorder based on the CIDI results and no record of depression diagnosis by a principal healthcare provider. Of 1 140 patients, 37% had CIDI-defined major depression, and 45% of these did not have a documented diagnosis of depression in their medical records. The researchers concluded that practitioners should be more attentive to diagnosing comorbid depression in HIV-infected patients. The problem may be worse in Africa; in a study of psychiatric disorders in HIV-positive individuals in urban Uganda, Petrushkin et al. (2005) found 82.6% total prevalence of psychiatric disorders, while no individual had been assessed for comorbid psychiatric conditions by their physician or were receiving mental health treatment. Research has shown that depression in PLHIV may reduce adherence to ARVs (Cook, 2002; Murray, Semrau, McCurley, Thea, Scott, Mwiya et al., 2009), accelerate progression to AIDS illness (Lesserman, Jackson, Petitto,
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Golden, Silva, Perkins et al., 1999), and further diminish quality of life (Cook, 2002). Effects of depression on quality of life of HIV patients With improved treatments and longer survival times for persons with HIV infection, the maintenance and improvement of their functioning and wellbeing (collectively referred to as ‘health-related quality of life’) have become major goals of treatment. Research has shown that depression in HIV-infected people is responsible for additional illness burden and further reduction in quality of life (Cook, 2002). The World Health Organization (WHO) defined quality of life (QOL) as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns; it is a broad-ranging concept, with QOL complexly affected by the person’s physical health, psychological state, level of independence, social relationships, and relationship to salient features of their environment (The WHOQOL Group, 1995). QOL is important for measuring the impact of chronic diseases (Patrick & Erickson, 1993), and it correlates well with a patient’s functional capacity and wellbeing. We know from studies of patients and general populations that mood disorders, particularly depression, have a substantial negative impact on a person’s health-related QOL (Jia, Uphold, Wu, Reid, Findley & Duncan, 2004). In fact, for most domains of functioning and wellbeing, depression is more debilitating than most medical conditions. A study in Nigeria of the relationship between depression and QOL in persons with HIV found that a diagnosis of depression was significantly correlated with poorer QOL in all domains, except for the social-relationship domain (Adewuya et al., 2008); in addition, lower educational level, poor social support, and the presence of medical problems were associated with poorer QOL. In a study to assess the impact of psychiatric conditions on health-related QOL, a national probability sample of persons with HIV receiving medical care in the United States was recruited (Sherbourne, Hays, Fleishman, Vitiello, Magruder, Bing et al., 2000). The participants were screened for psychiatric conditions with CIDI, and health-related QOL was rated with a 28-item instrument: 36% screened positive for a current depressive disorder and 26% for dysthymia. Moreover, the participants with a probable diagnosis of any mood disorder had significantly worse functioning and wellbeing than those without a mood disorder diagnosis on all health-related QOL measures, including the physical health and mental health composites (Sherbourne et al., 2000). These findings substantiate the considerable additional illness burden associated with mood disorders in HIV-infected people. A study in South Africa compared QOL in HIV-seropositive and HIV-seronegative patients and found poorer QOL in the seropositive patients (Hughes, Jelsma, Maclean, Darder & Tinise, 2004). Furthermore, depression, anxiety, and physical symptoms of pain or discomfort were significantly associated with poor QOL (Hughes et al., 2004). A study in the United States found lower QOL among participants with depressive disorder who were also receiving highly active antiretroviral treatment (HAART) (Liu, Johnson, Ostrow,
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Silvestre, Visscher & Jacobson, 2006). Another study in Taiwan similarly found that identifying and treating depression in patients with HIV or AIDS improved QOL (Yen, Tsai, Lu, Chen, Chen, Chen & Chen, 2004). In contrast, a study in Senegal assessed QOL in HIV patients receiving either an efavirenz-based or protease-inhibitor-based ARV drug and found 18% prevalence of depression and good scores for QOL (Poupard, Ngom Gueye, Thiam, Ndiaye, Girard, Delaporte et al., 2007); however, the researchers concluded that it is still important to monitor depression and QOL in the follow-up of HIV-infected patients. Management of psychiatric disorders in PLHIV The assessment and treatment of psychiatric disorders in PLHIV requires taking a comprehensive history from the patient and/or caregiver. This should especially focus on the history of the current complaint, past psychiatric history, past and present substance abuse, full medical history, a history of sexual-risk behaviour, and history of the patient’s adherence to previous HIV treatment regimens. Of equal importance is the identification of social support systems. A mental status examination (MSE) of the patient’s level of cognitive (knowledge-related) ability, appearance, emotional mood, and thought patterns at the time of the evaluation should also be conducted. In the psychotic patient one needs to focus specifically on the behaviour and appearance of the patient. His or her speech and speed of thoughts should be assessed, and mood symptoms, affect, suicidality and neuro-vegetative symptoms must be evaluated. Finally, perceptual disturbances, thought form, thought content, and insight and judgment also need to be assessed. A comprehensive and meticulous physical and neurological examination should be performed to exclude any organic causes for the presenting psychiatric symptoms. One should first examine for signs of delirium and rule out HIV-associated cognitive disorders. Medical diagnoses should be considered first, and only after that should a psychiatric diagnosis be entertained. A differential diagnosis needs to consider the presence of a pre-existing psychiatric illness, use of illicit substances, or the presence of cognitive impairment. The assessment and treatment of psychotic disorders in PLHIV can be very challenging. A useful delineation may be to divide psychosis in PLHIV into: 1) psychiatric disorders predating the HIV infection; 2) new-onset psychotic disorders; and, 3) disorders associated with medical conditions (e.g. delirium) or substance intoxication or withdrawal, as well as those that are likely to be complications of treatment (e.g. ARVs or anti-tuberculosis drugs). A good overall history, assessment of mental state, and a physical examination are usually important in making this delineation. Laboratory investigations are crucial in the assessment of delirium and substance intoxication. The choice of antipsychotic drugs depends largely on the patient, the presenting symptoms, the patient’s past response, a profile of potential side-effects, possible drug interactions, cost, and the pill burden for the chronically ill patient. Many patients with new-onset psychosis or psychosis associated with various medical conditions may only require short-term treatment with antipsychotic
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medication. However, some patients may require long-term maintenance/treatment with antipsychotic agents — here, special attention must be paid to the following factors: the typical antipsychotics are commonly used in resourceconstrained settings (e.g. low doses of haloperidol or chlorpromazine can be used); vigilance is required with regard to extrapyramidal side-effects; and newer atypical antipsychotics, such as risperidone or olanzepine, are now widely used in the treatment of psychotic disorders in HIV/ AIDS, with a lower propensity to cause extrapyramidal side-effects. The impact of depression on the course of the HIV infection has sometimes necessitated specific psychosocial and pharmacologic treatments targeting individuals with comorbid depression and HIV. Pharmacotherapy is the mainstay of treatment of moderate to severe depression. Several studies have demonstrated the efficacy of various antidepressant agents in HIV patients, but no single antidepressant has been found to be superior for treating HIV-infected patients on the whole (Olatunji, Mimiaga, O’Cleirigh & Safren, 2006). Aside from how well the pharmacology of the antidepressant matches a patient’s disease, the engine that drives effectiveness is the patient’s adherence. The general rule is to start at low doses of any medication and titrate up to a therapeutic dose slowly, so as to minimise early side-effects that may act as obstacles to adherence. Patients who show a partial response to an antidepressant drug (after adequate dosage and duration) should be offered an augmentation strategy. The choice of an antidepressant is largely based on the side-effects profile. Antidepressant drugs that are useful in treating depression in patients with HIV include amitriptyline, imipramine, clomipramine, fluoxetine, paroxetine, sertraline, fluvoxamine and venlafaxine (Elliot & Roy-Byrne, 1998). The use of psychostimulants, such as methylphenidate and dextroamphetamine, has also been found effective (Wagner & Rabkin, 2000). Clinicians often wonder about the interaction of antidepressants and HAART. Some interactions may occur but two points deserve emphasis: first, because depression is associated with reduction in adherence to HAART, untreated depression may be equally or more detrimental to HIV-disease progression than any medication interaction; second, experience in working with comorbid depression and HIV has not shown clinical significance of antidepressant/HAART interaction. Psychosocial intervention is an integral part of treatment for depression in patients with HIV. The combination of psychosocial intervention and medication was shown to be more effective for patients than either modality alone. Among the individual psychotherapies, interpersonal psychotherapy, cognitive-behavioural psychotherapy and supportive psychotherapy are effective in the treatment of depression in patients with HIV (Markowitz, Klerman, Clougherty, Spielman, Jocobsberg, Fishman et al., 1995). A social intervention, such as social-support group therapy, is also effective. Identifying and treating depression in patients with HIV could result in substantial improvement in their quality of life and potentially increase their medication adherence, which in turn would affect illness severity and progression.
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The treatment of anxiety disorders in cases of HIV or AIDS also requires a combination of psychosocial intervention and medication. Adequate counselling and relaxation techniques are sufficient to treat mild anxiety associated with the various crisis points in the course of HIV disease. For more severe anxiety disorders, antidepressants and cognitive behavioural techniques are useful. Every patient with HIV or AIDS presenting with a psychiatric disorder must also be assessed for suicidal risk, and in cases where the risk is high, the patient should be hospitalised for detailed evaluation and appropriate treatment. Substance abuse is a common problem in persons with HIV (Winstanley, Gust & Strathdee, 2006), hence physicians should exercise suspicion while assessing patients. When present, motivational interviews are important. Patients with severe problems, and who are motivated, should be hospitalised for detoxification and appropriate pharmacological and psychosocial treatment. Aims of the study Despite the fact that about 3.6% of Nigerians are living with HIV, there are no studies on depression and quality-of-life issues in this group in the northern part of the country. Thus, this study aimed to determine the frequency of depressive disorder in a sample of Nigerian patients with HIV and to determine to what extent the sample of HIV patients had ever been diagnosed or treated for depressive disorder by an attending physician. The study also sought to determine the impact of depression on the quality of life of patients with HIV in northern Nigeria. Methods The participants were made up of a consecutive sample of 310 patients with HIV attending the virology clinic at Ahmadu Bello University Teaching Hospital in Zaria, Nigeria, during September to December 2006, and who also gave informed consent and met the study’s inclusion criteria. Eligibility criteria included patients with confirmed HIV infection who were on ARV medication; the study excluded patients known to have other comorbid chronic medical conditions, patients known to have other psychiatric conditions besides depression, and those found to have marked cognitive impairment. To determine whether patients were not eligible on the grounds of marked cognitive impairment, all the potential participants were initially screened for cognitive impairment, by a single investigator carrying out a mental state examination. Thus, the patients were assessed for recent memory, remote memory, and orientation in person, place and time. Those found to have impaired memory and/or disorientation in person, place, or time were excluded from the study. Ethical clearance for the study was obtained from the hospital’s research and ethics committee. A sociodemographic 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. Those with a CES-DR score 16 were considered as having significant depressive symptoms and were then administered the relevant sections of the Schedule
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for Clinical Assessment in Neuropsychiatry (SCAN). Thirty participants (about 10% of the sample size) who fell slightly short of attaining the CES-DR cut-off score of 16 were randomly selected and also administered the SCAN. The Research Diagnostic Criteria (RDC) of the International Classification of Diseases (ICD-10) (see World Health Organization, 1993) was used to generate a clinical diagnosis of depressive disorder based on any depressive symptoms noted by way of the SCAN. The medical records of all participants (from the previous six months) were screened for documentation of depressive symptoms or treatment with antidepressants by an attending physician. ‘Underdiagnosis of depression’ was defined as a SCAN diagnosis of depression without any documentation of depression in the participant’s medical record. Next, the WHOQOL-BREF questionnaire was administered to the participants. The participants’ quality of life (QOL) in all domains of was categorised as ‘poor,’ ‘average’ or ‘good.’ The domain for overall QOL and health satisfaction were categorised subjectively by the participants, while domains 1 through 4 were categorised by the authors on the basis of the domain mean score (±1 standard deviation [SD]). Domain scores 1 SD from the domain mean were categorised as ‘good’; and domain scores between 1 SD below and above the domain mean were categorised as ‘average.’ SPSS-12 software was used for entering and analysing the data. A chi-square test was used to characterise the significance of the difference between QOL in depressed HIV/AIDS patients compared to non-depressed HIV/AIDS patients. 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 ART was 17.7 months (±5.2). The participants’ sociodemographic characteristics are presented in Table 1. The results show that 21.3% (n = 66) of the participants had significant depressive symptoms (i.e. CES-DR score >16) while 78.7% (n = 244) had no significant depressive symptoms (i.e. CES-DR score 0.05).
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The QOL categorisations for the participants with depressive disorder were compared with those for participants without depressive disorder (see Table 2). During the data analysis we merged the ‘average’ and ‘good’ categories of QOL in all domains to generate the single ‘average or above’ category because some cells in the resulting table of QOL categorisation (for both the participants with and those without depressive disorder) had small values ( 0.05 (domain mean score = 62.99, SD = 9.28)
psychiatric morbidity, especially depression, so as to enhance appropriate care and improve treatment outcomes. Simple screening instruments for psychiatric conditions should be provided in all HIV/AIDS treatment centres so as to improve case identification. Consultation-liaison psychiatry services should be routinely extended to patients receiving treatment for HIV or AIDS. Again, mental health must be integrated into primary healthcare and global HIV/ AIDS initiatives. Nigerian universities should allocate more time to psychiatry training in their curriculum so as to better equip medical students with the knowledge required to face challenges relating to psychiatry as doctors. There are some limitations to this study. Participants who were asked to recall and rate QOL issues may give incorrect answers due to problems with memory. Because the study was hospital-based, the results may not be generalised to the entire population of PLHIV; however, the findings provide insight to those who approach medical facilities for treatment. The authors did not remove the somatic items in the CES-D and this might have confounded the measure of depression. Lastly, the study did not take into consideration the participants’ stage of HIV disease (e.g. CD4 cell count) in relation to depression, which may be relevant and thus an important area for future research. Acknowledgments — We are grateful to colleagues in the Department of Psychiatry at Ahmadu Bello University Teaching Hospital, and to the doctors and nursing staff at the virology clinic for their assistance during the period of data collection.
No depressive disorder (n = 266) n (%)
Total (n = 310) n (%)
28 (63.6) 16 (36.4)
30 (11.3) 236 (88.7)
58 (18.7) 252 (81.3)
36 (81.8) 8 (18.2)
68 (25.6) 198 (74.4)
104 (33.5) 206 (66.5)
20 (45.5) 24 (54.5)
24 (9) 242 (91)
44 (14.2) 266 (85.8)
28 (63.6) 16 (36.4)
12 (4.5) 254 (95.5)
40 (12.9) 270 (87.1)
28 (63.6) 16 (36.4)
48 (18.1) 218 (81.9)
76 (24.5) 234 (75.5)
4 (9.1) 40 (90.9)
10 (3.8) 256 (96.2)
14 (4.5) 296 (95.5)
The authors — Victor Obiajulu Olisah (MBBS, FWACP Psych) is a consultant psychiatrist and lecturer in the Department of Psychiatry at Ahmadu Bello University. Olusegun Baiyewu (MBBS, FWACP Psych, FMC Psych) is a consultant psychiatrist and professor in the Department of Psychiatry at University College Hospital in Ibadan. Taiwo Lateef Sheikh (MSc, MBBS, FWACP Psych) is a consultant psychiatrist and senior lecturer in the Department of Psychiatry at Ahmadu Bello University.
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