Risk of deliberate self-harm and factors associated with suicidal behaviour among asymptomatic individuals with human immunodeficiency virus infection Gala C, Pergami A, Catalan J, Riccio M, Durbano F, Musicco M, Baldeweg T, Invernizzi G. Risk of deliberate self-harm and factors associated with suicidal behaviour among asymptomatic individuals with human immunodeficiency virus infection. Acta Psychiatr Scand 1992: 86: 70-75.
The study was aimed at evaluating the risk of deliberate self-harm (DSH) and factors associated with suicidal behaviour in 21 3 asymptomatic individuals with human immunodeficiency virus (HIV) infection in 3 transmission categories (68 gay men, 123 intravenous drug users and 22 heterosexuals). The results showed that 12 HIV-seropositive (HIV + ) subjects were involved in DSH after the notification of a positive HIV test result, of which 8 occurred within 6 months and 4 between 6 months and 3 years. HIV + subjects with a past psychiatric history showed a 7.7-fold increase in the relative risk of DSH, and HIV + subjects with a history of D S H showed a 5-fold increase in the relative risk of D S H compared with HIV + individuals without a past psychiatric history and a history of DSH. Professionals involved in the care of HIV + individuals need to be aware of this risk, especially in the first few months after notification of HIV status and also at later stages of acquired immunodeficiency syndrome.
Human immunodeficiency virus (HIV) infection can be associated with significant prevalence rates of mental disorder, including adjustment reactions, mood, anxiety and substance abuse disorders (1-4). Furthermore, investigators have raised concerns about an increased risk of suicide among HIVseropositive (HIV + ) and acquired immunodeficiency syndrome (AIDS) individuals (5). In one study from the United States, Marzuk et al. (6) reported a 36-fold increase in the relative risk of suicide in men with AIDS aged 20-59 compared with men of the same age from the general population and a 66-fold increase compared with the general population. In a similar study from California, Kizer et al. (7) showed that men with AIDS were 17 times more likely to die from suicide than men of the same age from the general population. In a retrospective evaluation of 2255 death certificates of AIDS individuals in Texas, Plott et al. (8) calculated a significantly higher suicide rate of 222/100,000, compared with a rate of 13/100,000 reported from the general population. Case reports (9, 10) and other studies (1 1) confirmed a high risk of suicide in people with AIDS. Studies in asymptomatic HIV + 70
C. Gala ’, A. Pergami’, J. Catalan’, M. Riccio’, F. Durbano’, M. Musicco3, T. Baldeweg’, G. lnvernizzi
’
’ Institute of Psychiatry, University of Milan Medical School, Italy, Academic & Clinical Department of Psychological Medicine, Charing Cross & Westminster Medical School, London, United Kingdom, Institute of Advanced Biomedical Technologies, Italian National Research Council, Milan, Italy
Key words: HIV; AIDS; deliberate self-harm; suicidal risk; homosexuality; drug abuse Dr A. Pergami, Academic & Clinical Department of Psychological Medicine, Charing Cross & Westminster Medical School, 1 Udall Street, London S W l P 2NS, United Kingdom Accepted for publication February 13, 1992
individuals are lacking and data from available reports do not allow the evaluation of differences in suicide risk (12). Assessment of suicidal risk highlighted similarities between deliberate self-harm (DSH) among HIV + individuals and those identified in the context of general medical and psychiatric services as risk factors for a suicide attempt (13-18). Suicide risk in HIV+ individuals is likely to be similar to those of subjects with debilitating and potentially fatal illnesses such as renal dialysis, multiple sclerosis and cancer (19), and higher than those of the general population (20). Early studies on men with cancer have shown a 2.3-fold increase in the relative risk of suicide compared with the general population and no increased risk for women (21), whereas other researchers have found a relative risk of 1.9 in women and 1.3 in men (22). In addition, a number of suicide vulnerability variables were found to be associated with such chronic and lifethreatening illnesses as cancer. These characteristics include pre-existing psychopathology, helplessness and hopelessness, advanced illness and poor prognosis, prior suicide attempt history, physical exhaus-
Deliberate self-harm and HIV infection
tion and fatigue (23). All these factors may be present in HIV infection but the current magnitude of HIV + individuals with DSH tendencies in Europe remains unknown (24). There are several methodological problems in reports on suicidal behaviour (25). These may include sampling strategies, study design, ascertainment bias and definition of outcome measures. In the field of HIV infection, other specific problems may be underreporting of HIV-related suicides and difficulties in differentiating between suicide attempts and nonsuicidal overdoses of heroin in drug users. To date, most studies of suicidal behaviour among HIV + individuals have been retrospective or case-control studies (24). Most of the evidence comes from studies of gay men (13-15) and little is known about the risk of DSH and suicide among other HIV+ individuals such as intravenous drug users (IVDUs) and heterosexuals. This is of interest in view of the predictive importance of DSH for completed suicide, especially those who have a history of mental disorders (1, 14, 17, 26) and who have been diagnosed as having AIDS for at least 6 months (6). The aims of this study were: 0 to evaluate the prevalence of suicidal behaviour among HIV + asymptomatic subjects after they found out that they were infected; 0 to identify the risk of D S H among this population; and 0 to test whether psychiatric history and a history of D S H are factors predictive of DSH. Material and methods Subjects
A total of 266 HIV + consecutive attenders at the outpatient service of the Department of Infectious Diseases of the University of Milan Medical School were approached from January 1988 to December 1989; 213 HIV+ subjects (168 men, 79%; 45 women, 21%) agreed to enter the study (response rate: 80%). The Department is one of the 3 hospitalbased clinics authorized to perform HIV testing by the Italian National Institute of Health in Milan. Subjects were followed up on a quarterly basis for 42 months during the scheduled research clinic visit. All had been tested for HIV antibodies before study entry, and all knew their serologic status at the time of the study. HIV status was established by enzymelinked immunosorbent assay, confirmed with the Western blot test, and all subjects met the Centers for Disease Control criteria for stages I1 and I l l (27). HIV+ subjects were categorized in 3 mutually exclusive subgroups: 68 gay men (32%); 123 intravenous drug users (IVDUs) (48%) and 22 heterosexuals (20%).
Measures
Demographic data. Information on sex, age, level of education, transmission categories of the respondents and time elapsed since a positive HIV test result were gathered. According to the Italian schooling system, education up to 8 years was considered primary compulsory education, up to 13 years secondary education and up to 20 years college or university education. Psychiatric assessment. All subjects were assessed by means of a semistructured interview aimed at collecting information about: past psychiatric history, with particular attention to DSH prior to HIV infection; and deliberate self-harm after the notification of HIV infection. Subjects were considered to have a past psychiatric history on the basis of a history of outpatient psychiatric care or at least one admission to a psychiatric hospital at some point in the past. We used DSH as a comprehensive definition that included deliberate self-poisoning and deliberate self-injury to define nonaccidental behaviour without implying any specific motive (28). DSH by means of heroin overdose was applied when the patient mentioned a serious intent to die at interview, to differentiate from a nonsuicidal overdose of heroin. In this study, we report only the evaluation of risk of DSH and factors associated with suicidal behaviour in HIV + individuals. A comprehensive evaluation of mental disorders and psychosocial complications in our sample using standardized self-report questionnaires and evaluating current psychopathological status is reported elsewhere (17, 18). Procedures. Subjects were consecutively approached during a scheduled research clinic visit by the examining psychiatrists (A.P., F.D. and C.G.). All patients gave informed consent to enter the study. Only subjects who were followed up for 42 months on a quarterly basis during the scheduled research clinic visit were included in the study. Of the 53 individuals with HIV infection that dropped out of the study during the 42 months follow-up, 35 were IVDUs (25 man and 10 women), 13 gay men and 5 heterosexuals (3 men and 2 women). Data were collected prospectively from January 1988 to December 1989 and in January 1990; the clinical records were examined to find out individuals who presented DSH before and after the knowledge of HIV infection. Statistical analysis. Data were analysed using the Statistical Package for the Social Sciences (SPSSX) (29). Kruskal-Wallis one-way analysis of variance (ANOVA) and multivariate ANOVA (MANOVA) 71
Gala et al. were used to identify predictive factors for DSH among HIV + individuals. The Kaplan-Meyer method (30) was used to evaluate the cumulative probability risk of DSH among HIV + subjects. All analysis used the 0.05 level of significance. Results
Characteristics of the sample
The mean age for the total sample was 30 years (range: 20-60) and the mean duration of education was 11 years (range: 5-20). Gay men were older than IVDUs and heterosexuals ( P < 0.05) and IVDUs were less educated than gay men and heterosexuals (P
The study was aimed at evaluating the risk of deliberate self-harm (DSH) and factors associated with suicidal behaviour in 21 3 asymptomatic individuals with human immunodeficiency virus (HIV) infection in 3 transmission categories (68 gay men, 123 intravenous drug users and 22 heterosexuals). The results showed that 12 HIV-seropositive (HIV + ) subjects were involved in DSH after the notification of a positive HIV test result, of which 8 occurred within 6 months and 4 between 6 months and 3 years. HIV + subjects with a past psychiatric history showed a 7.7-fold increase in the relative risk of DSH, and HIV + subjects with a history of D S H showed a 5-fold increase in the relative risk of D S H compared with HIV + individuals without a past psychiatric history and a history of DSH. Professionals involved in the care of HIV + individuals need to be aware of this risk, especially in the first few months after notification of HIV status and also at later stages of acquired immunodeficiency syndrome.
Human immunodeficiency virus (HIV) infection can be associated with significant prevalence rates of mental disorder, including adjustment reactions, mood, anxiety and substance abuse disorders (1-4). Furthermore, investigators have raised concerns about an increased risk of suicide among HIVseropositive (HIV + ) and acquired immunodeficiency syndrome (AIDS) individuals (5). In one study from the United States, Marzuk et al. (6) reported a 36-fold increase in the relative risk of suicide in men with AIDS aged 20-59 compared with men of the same age from the general population and a 66-fold increase compared with the general population. In a similar study from California, Kizer et al. (7) showed that men with AIDS were 17 times more likely to die from suicide than men of the same age from the general population. In a retrospective evaluation of 2255 death certificates of AIDS individuals in Texas, Plott et al. (8) calculated a significantly higher suicide rate of 222/100,000, compared with a rate of 13/100,000 reported from the general population. Case reports (9, 10) and other studies (1 1) confirmed a high risk of suicide in people with AIDS. Studies in asymptomatic HIV + 70
C. Gala ’, A. Pergami’, J. Catalan’, M. Riccio’, F. Durbano’, M. Musicco3, T. Baldeweg’, G. lnvernizzi
’
’ Institute of Psychiatry, University of Milan Medical School, Italy, Academic & Clinical Department of Psychological Medicine, Charing Cross & Westminster Medical School, London, United Kingdom, Institute of Advanced Biomedical Technologies, Italian National Research Council, Milan, Italy
Key words: HIV; AIDS; deliberate self-harm; suicidal risk; homosexuality; drug abuse Dr A. Pergami, Academic & Clinical Department of Psychological Medicine, Charing Cross & Westminster Medical School, 1 Udall Street, London S W l P 2NS, United Kingdom Accepted for publication February 13, 1992
individuals are lacking and data from available reports do not allow the evaluation of differences in suicide risk (12). Assessment of suicidal risk highlighted similarities between deliberate self-harm (DSH) among HIV + individuals and those identified in the context of general medical and psychiatric services as risk factors for a suicide attempt (13-18). Suicide risk in HIV+ individuals is likely to be similar to those of subjects with debilitating and potentially fatal illnesses such as renal dialysis, multiple sclerosis and cancer (19), and higher than those of the general population (20). Early studies on men with cancer have shown a 2.3-fold increase in the relative risk of suicide compared with the general population and no increased risk for women (21), whereas other researchers have found a relative risk of 1.9 in women and 1.3 in men (22). In addition, a number of suicide vulnerability variables were found to be associated with such chronic and lifethreatening illnesses as cancer. These characteristics include pre-existing psychopathology, helplessness and hopelessness, advanced illness and poor prognosis, prior suicide attempt history, physical exhaus-
Deliberate self-harm and HIV infection
tion and fatigue (23). All these factors may be present in HIV infection but the current magnitude of HIV + individuals with DSH tendencies in Europe remains unknown (24). There are several methodological problems in reports on suicidal behaviour (25). These may include sampling strategies, study design, ascertainment bias and definition of outcome measures. In the field of HIV infection, other specific problems may be underreporting of HIV-related suicides and difficulties in differentiating between suicide attempts and nonsuicidal overdoses of heroin in drug users. To date, most studies of suicidal behaviour among HIV + individuals have been retrospective or case-control studies (24). Most of the evidence comes from studies of gay men (13-15) and little is known about the risk of DSH and suicide among other HIV+ individuals such as intravenous drug users (IVDUs) and heterosexuals. This is of interest in view of the predictive importance of DSH for completed suicide, especially those who have a history of mental disorders (1, 14, 17, 26) and who have been diagnosed as having AIDS for at least 6 months (6). The aims of this study were: 0 to evaluate the prevalence of suicidal behaviour among HIV + asymptomatic subjects after they found out that they were infected; 0 to identify the risk of D S H among this population; and 0 to test whether psychiatric history and a history of D S H are factors predictive of DSH. Material and methods Subjects
A total of 266 HIV + consecutive attenders at the outpatient service of the Department of Infectious Diseases of the University of Milan Medical School were approached from January 1988 to December 1989; 213 HIV+ subjects (168 men, 79%; 45 women, 21%) agreed to enter the study (response rate: 80%). The Department is one of the 3 hospitalbased clinics authorized to perform HIV testing by the Italian National Institute of Health in Milan. Subjects were followed up on a quarterly basis for 42 months during the scheduled research clinic visit. All had been tested for HIV antibodies before study entry, and all knew their serologic status at the time of the study. HIV status was established by enzymelinked immunosorbent assay, confirmed with the Western blot test, and all subjects met the Centers for Disease Control criteria for stages I1 and I l l (27). HIV+ subjects were categorized in 3 mutually exclusive subgroups: 68 gay men (32%); 123 intravenous drug users (IVDUs) (48%) and 22 heterosexuals (20%).
Measures
Demographic data. Information on sex, age, level of education, transmission categories of the respondents and time elapsed since a positive HIV test result were gathered. According to the Italian schooling system, education up to 8 years was considered primary compulsory education, up to 13 years secondary education and up to 20 years college or university education. Psychiatric assessment. All subjects were assessed by means of a semistructured interview aimed at collecting information about: past psychiatric history, with particular attention to DSH prior to HIV infection; and deliberate self-harm after the notification of HIV infection. Subjects were considered to have a past psychiatric history on the basis of a history of outpatient psychiatric care or at least one admission to a psychiatric hospital at some point in the past. We used DSH as a comprehensive definition that included deliberate self-poisoning and deliberate self-injury to define nonaccidental behaviour without implying any specific motive (28). DSH by means of heroin overdose was applied when the patient mentioned a serious intent to die at interview, to differentiate from a nonsuicidal overdose of heroin. In this study, we report only the evaluation of risk of DSH and factors associated with suicidal behaviour in HIV + individuals. A comprehensive evaluation of mental disorders and psychosocial complications in our sample using standardized self-report questionnaires and evaluating current psychopathological status is reported elsewhere (17, 18). Procedures. Subjects were consecutively approached during a scheduled research clinic visit by the examining psychiatrists (A.P., F.D. and C.G.). All patients gave informed consent to enter the study. Only subjects who were followed up for 42 months on a quarterly basis during the scheduled research clinic visit were included in the study. Of the 53 individuals with HIV infection that dropped out of the study during the 42 months follow-up, 35 were IVDUs (25 man and 10 women), 13 gay men and 5 heterosexuals (3 men and 2 women). Data were collected prospectively from January 1988 to December 1989 and in January 1990; the clinical records were examined to find out individuals who presented DSH before and after the knowledge of HIV infection. Statistical analysis. Data were analysed using the Statistical Package for the Social Sciences (SPSSX) (29). Kruskal-Wallis one-way analysis of variance (ANOVA) and multivariate ANOVA (MANOVA) 71
Gala et al. were used to identify predictive factors for DSH among HIV + individuals. The Kaplan-Meyer method (30) was used to evaluate the cumulative probability risk of DSH among HIV + subjects. All analysis used the 0.05 level of significance. Results
Characteristics of the sample
The mean age for the total sample was 30 years (range: 20-60) and the mean duration of education was 11 years (range: 5-20). Gay men were older than IVDUs and heterosexuals ( P < 0.05) and IVDUs were less educated than gay men and heterosexuals (P
