Depression is a major issue in South Africa among people living with HIV, but has received little attention. New studies have highlighted strong links between HIV-AIDS and mental illness including depression, heightened risks of violence faced by children affected by the virus, and some ways to tackle the problem, writes Karen MacGregor for MedicalBrief.
This is critical because having a psychiatric disorder that affects quality of life increases non-adherence to antiretroviral treatment – and is associated with sexual behavior that raises the risk of infecting people who do not have HIV.
Extent of the problem
Research in Sub-Saharan Africa has found that one in three people living with HIV suffers from depression.
There are numerous stresses that drive mental health problems in HIV-positive people, including depression after diagnosis with a chronic illness, the stigma and discrimination that accompany HIV-positive status in many communities, and physical symptoms of the virus.
A just-published South African study uncovered major depressive disorder among one in seven (14%) people seeking HIV testing. There was generalised anxiety disorder among 5%, post-traumatic stress disorder among 5% and alcohol use disorder among 20%.
The prevalence of common mental disorders was measured through interviews with 485 people seeking testing in five community centres. Ashraf Kagee and colleagues from Stellenbosch University reported in the study published in Aids and Behaviour last month on the need to integrate mental health screening into voluntary HIV counseling and testing.
In AIDS and Behavior in April, researchers from the universities of Cape Town and Columbia in New York reported on depression among pregnant women starting antiretroviral therapy in the Western Cape: among 623 participants, one in five had elevated depression scores.
“Depression, HIV-related stigma and low levels of social support may be particularly prevalent and adversely affect health and treatment outcomes among HIV-infected pregnant women,” they wrote, also proposing interventions to reduce stigma and tackle depression risk.
Children, HIV and violence
The link between violence and mental health issues is well established, and lowering its occurrence can be a powerful intervention to help improve overall health and treatment adherence – and lower HIV transmission – in HIV-affected communities.
Exposure to violence and its connection to mental health among nearly 1,000 children affected by HIV-AIDS in South Africa and Malawi was studied by researchers from the universities of Stellenbosch and Cape Town as well as University College London.
They found levels of violence in the home and the community to be high in both countries. “HIV-negative children who lived with an HIV-positive person experienced most violence overall, followed by HIV-positive children. Children unaffected by HIV experienced least violence,” they wrote in an article in AIDS Care in March.
Nearly half of the children aged four to 13 years had been exposed to interpersonal violence between adults in the home, and more than two in five had been exposed to violence in their community. Harsh discipline was common, with 48% of carers reporting striking a child with an implement, or on the head or face, and 45% meting out harsh psychological punishment.
Children exposed to violence are more likely to engage in harmful use of substances, risky sexual behaviour, become HIV-infected, bully others, take part in rape and partner violence later in life, be abusive parents, and be more at risk of abuse as adults. Harsh physical abuse during childhood has been linked with increased depression and attempted suicide.
“Importantly, many of the risk factors for violence against children are particularly prevalent in families and communities affected by HIV-AIDS,” wrote the researchers.
Children in the study were attending community programmes, and follow-up research showed this could mitigate negative impacts of violence exposure. “Community-based organisations working to improve psychosocial outcomes for vulnerable children affected by HIV-AIDS should integrate violence prevention programming into their work.”
Screening and treatment can help
African research is backed up by international studies that have found depression and other mental illnesses to be seriously under-diagnosed among HIV-infected people, under-treated and associated with poor health outcomes.
New research led by Lotte Rodkjaer, at Aarhus University Hospital and Odense University Hospital in Denmark, found major depression to be the most common psychiatric comorbidity among some 500 HIV-infected people, with a prevalence of between 20% and 37%.
“Nearly one-third of HIV-infected individuals are affected by depression, which is nearly twice as many as in patients with other chronic conditions such as diabetes or cardiovascular disease,” she wrote in HIV Medicine last month.
The Danish researchers suggest that mental health should be routinely monitored and a three-step approach should be used to screen, identify whether there is a risk of depression and then provide diagnosis, counseling and treatment as part of improving patients’ overall health.
Previous research has established that treating depression improves adherence to antiretroviral therapy. “As HIV-infected individuals live longer as a result of medical advances, depression in a gradually aging HIV-infected cohort will remain an issue that needs to be addressed clinically to increase adherence to treatment, quality of life and linkage to care.”
Tackling the problem
The research has highlighted a variety of strategies that could alleviate the serious problem of HIV and depression in South Africa and across the continent, ranging from screening and monitoring mental health among HIV-positive people to counseling, treatment and community-based interventions.
Improving food security through social support has emerged as an important strategy to ease depression, according to a recent article in Social Science and Medicine. Research among 1,200 pregnant women in peri-urban Cape Town found that food insufficiency was strongly associated with depressive symptoms – with a 6.5% difference in severity per day of hunger.
Reports of the psychiatric repercussions of HIV are rising and dealing with mental health problems is an essential step in controlling the HIV epidemic. However, writes Etheldreda Nakimuli-Mpungu, a psychiatric epidemiologist at Makerere University in Uganda, “mental health care is not yet part of the HIV care package in the region”.
Makerere developed a group support psychotherapy model to treat depression, by providing emotional and social support, and teaching positive coping and income-generating skills.
HIV-positive people suffering from depression met in eight weekly, gender-specific sessions and – unlike with previous studies – were eager to engage. This was possibly because the community helped develop the model, trained mental health workers were able to create a safe environment, and facilitators taught income-generating skills to mitigate poverty.
“Our study provides the first evidence of the success of this kind of group intervention in breaking the negative cycle of poverty and poor mental health in a resource-poor setting,” wrote Nakimuli-Mpungu. Six months after the programme, 80% of participants said it had reduced depression and motivated positive changes in their lives. “Our findings also suggest that it is possible to roll out this kind of treatment in poorly resourced rural areas.”
Back home, the South African Depression and Anxiety Group talks about the “multiple stigmatisation” faced by many HIV-positive people, which discourages them from seeking treatment, including for mental illness.
It cites Lourens Schlebusch, emeritus professor and former head of behavioural medicine at the Nelson R Mandela School of Medicine at the University of KwaZulu-Natal, who found that patients with HIV and AIDS were 36 times more likely to commit suicide.
“This is mainly because of the anxiety and depression that result from their condition,” says SADAG on its website. Also, home-based care-givers who are depressed are unmotivated and unable to effectively assist severely ill patients.
The organisation has a rural project operating in all provinces that among other work educates home-based carers about depression and anxiety and initiates psychosocial support groups in HIV-affected communities.
Naazia Ismail, project manager at SADAG, told MedicalBrief that carers were trained to identify and alleviate mental health-related illnesses among patients in an initiative that urgently needed to be scaled up across the country – but cannot be because of lack of funding or interest in this critical aspect of HIV treatment and prevention.
“The Prevalence of Common Mental Disorders Among South Africans Seeking HIV Testing”
We administered the Structured Clinical Interview for the DSM to 485 persons seeking HIV testing at five community testing centres in South Africa to determine the prevalence of common mental disorders among this population. The prevalence estimates for the various disorders were as follows: major depressive disorder: 14.2 % (95 % CI [11.1, 17.3]); generalised anxiety disorder 5.0 % (95 % CI [3.07, 6.93]); posttraumatic stress disorder 4.9 % (95 % CI [2.98, 6.82]); and alcohol use disorder 19.8 % (95 % CI [16.26, 23.34]). Our findings imply the need to research the integration of screening and referral trajectories in the context of voluntary HIV counselling and testing.Article in AIDS and Behavior
“Simple and practical screening approach to identify HIV-infected individuals with depression or at risk of developing depression”
L Rodkjaer, C Gabel, T Laursen, M Slot, P Leutscher, N Christensen, J Holmskov and M Sodemann
Studies have shown that depression and other mental illnesses are under-diagnosed among HIV-infected individuals. The aim of this study was to evaluate the use of mental health history and questionnaire-based screening instruments to identify HIV-infected individuals at risk of depression.
The Beck Depression Inventory II (BDI-II) was used to assess the prevalence and severity of depressive symptoms among HIV-infected individuals attending two out-patient clinics in Denmark. HIV-infected individuals with a BDI-II score ≥ 20 were offered a clinical evaluation by a consultant psychiatrist. The BDI-II score was compared to the outcome of mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool.
A total of 501 HIV-infected individuals were included in the study. Symptoms of moderate/major depression (BDI-II score ≥ 20) were observed in 111 patients (22%); 65 of these patients consulted a psychiatrist, of whom 71% were diagnosed with a co-existing disorder. The BDI-II score was compared to the outcome of a mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool. The two questions showed a sensitivity and specificity of 95% and 68%, respectively, for diagnosis of current depression or risk of depression. A previous psychiatric history and substance abuse were independently associated with an increased risk of depression.
We suggest that the mental health of HIV-infected individuals should be reviewed and a “risk-flag” three-step approach should be used (1) to screen routinely with the two verbal questions suggested by the EACS, (2) to identify whether there is a risk of depression and then screen with the BDI-II, and (3) to identify whether there is still a risk and then perform a full evaluation and obtain an accurate psychiatric diagnosis by a psychiatrist.Article in HIV Medicine
“Social Support, Stigma and Antenatal Depression Among HIV-Infected Pregnant Women in South Africa”
Kirsty Brittain, Claude A. Mellins, Tamsin Phillips, Allison Zerbe, Elaine J. Abrams, Landon Myer, Robert H. Remien
Depression, HIV-related stigma and low levels of social support may be particularly prevalent and adversely affect health and treatment outcomes among HIV-infected pregnant women. We examined factors associated with social support and stigma among pregnant women initiating antiretroviral therapy in the Western Cape, South Africa; and explored associations with depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) in linear regression models.
Among 623 participants, 11 and 19 % had elevated EPDS scores using thresholds described in the original development of the scale (scores ≥13 and ≥10, respectively). Social support and stigma were highly interrelated and were associated with depressive symptoms. Stigma was observed to moderate the association between social support and depression scores; when levels of stigma were high, no association between social support and depression scores was observed. Elevated depression scores are prevalent in this setting, and interventions to reduce stigma and to address risk factors for depressive symptoms are needed.Article in AIDS and Behavior
“Food insufficiency, depression, and the modifying role of social support: Evidence from a population-based, prospective cohort of pregnant women in peri-urban South Africa”
Alexander C. Tsai, Mark Tomlinson, W. Scott Comulada and Mary Jane Rotheram-Borus
Food insecurity has emerged as an important, and potentially modifiable, risk factor for depression. Few studies have brought longitudinal data to bear on investigating this association in sub-Saharan Africa.
To estimate the association between food insufficiency and depression symptom severity, and to determine the extent to which any observed associations were modified by social support.
Methods and results
We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a three-year cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 months, 18 months, and 36 months (85% retention). A validated, single-item food insufficiency measure inquired about the number of days of hunger in the past week. Depression symptom severity was measured using the Xhosa version of the 10-item Edinburgh Postnatal Depression Scale.
In multivariable regression models with cluster-correlated robust estimates of variance, lagged food insufficiency had a strong and statistically significant association with depression symptom severity (β = 0.70; 95% CI, 0.46–0.94), suggesting a 6.5% relative difference in depression symptom severity per day of hunger. In stratified analyses, food insufficiency had a statistically significant association with depression only among women with low levels of instrumental support. Using quantile regression, we found that the adverse impacts of food insufficiency were experienced to a greater degree by women in the upper end of the conditional distribution of depression symptom severity. Estimates from fixed-effects regression models and fixed-effects quantile regression models, accounting for unobserved confounding by time-invariant characteristics, were similar.
Food insufficiency was associated with depression symptom severity, particularly for women in the upper end of the conditional depression distribution. Instrumental social support buffered women against the adverse impacts of food insufficiency.Article in Social Science and Medicine
“Exposure to violence and psychological well-being over time in children affected by HIV/AIDS in South Africa and Malawi”
Many of the risk factors for violence against children are particularly prevalent in families and communities affected by HIV/AIDS. Yet, in sub-Saharan Africa, where HIV rates are high, efforts to prevent or address violence against children and its long-lasting effects are hampered by a lack of evidence. We assessed the relationship between violence exposure and mental health among HIV-affected children attending community-based organisations in South Africa (n = 834) and Malawi (n = 155, total sample n = 989) at baseline and 12–15-month follow-up. Exposure to violence in the home and in the community was high.
HIV-negative children who lived with an HIV-positive person experienced most violence overall, followed by HIV-positive children. Children unaffected by HIV experienced least violence (all p < .05). Interpersonal violence in the home predicted child depression (β = 0.17, p < .001), trauma symptoms (β = 0.17, p < .001), lower self-esteem (β = −0.17, p < .001), and internalising and externalising behavioural problems (β = 0.07, p < .05), while exposure to community violence predicted trauma symptoms (β = 0.16, p < .001) and behavioural problems (β = 0.07, p < .05). Harsh physical discipline predicted lower self-esteem (β = −0.18, p < .001) and behavioural problems for children (β = 0.24, p < .001).
Exposure to home (OR: 1.89, 95% CI: 1.23–2.85) and community violence predicted risk behaviour (OR: 2.39, 95% CI: 1.57–3.62). Over time, there was a decrease in depressed mood and problem behaviours, and an increase in self-esteem for children experiencing different types of violence at baseline. This may have been due to ongoing participation in the community-based programme. These data highlight the burden of violence in these communities and possibilities for programmes to include violence prevention to improve psychosocial well-being in HIV-affected children.Article in AIDS Care