European Journal of Cardiovascular Medicine

HIV/AIDS places an increasing burden on socioeconomics, families, and communities. HAART transformed HIV into a chronic disease. Patients face physical symptoms, co-morbidities, drug side effects, stigma, cultural beliefs, and discrimination, affecting Quality of Life (QOL).

WHO defines QOL as "individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, standards, expectations and concerns".1 Assessing QOL evaluates perceived disease burden, health changes over time, and treatment efficacy.

Diagnosis creates overwhelming stress and catastrophic life changes due to stigma. Psychiatric conditions increase risk behaviours, lower care access, reduce therapy adherence, and heighten medical co-morbidity, leading authors to label HIV a "psychiatric epidemic." Depression impairs disease course, heightens infection susceptibility, and causes non-compliance. Barriers to identification include patient fear of stigma and healthcare providers viewing depression as a normal reaction rather than a treatable condition.

The 2025 estimates show that about 41 million people live with HIV. Transmission occurs via sexual contact, blood products, and mother-to-child (intrapartum, perinatally, breast milk). HAART suppresses viral replication to undetectable levels. With 12% of them still unaware of

their status, untreated mental illness in this population leads to non-adherence, higher viral loads, increased immunosuppression, morbidity, mortality, and transmission risk.

Links Between HIV & Psychiatry:

(i) Malignant course and stigma cause severe emotional reactions.2 (ii) Direct CNS effects cause neurocognitive disturbances, psychosis, or behavioural changes. (iii) Opportunistic neurological/systemic infections cause neuropsychiatric problems. (iv) HAART medications induce psychiatric side effects. (v) Severe mental illness increases HIV vulnerability. (vi) Substance abuse connects directly (IV abuse) and indirectly (risky sexual behaviour). (vii) Emotional factors and substance abuse impair treatment adherence.

Specific Psychiatric Disorders in PLWHA

Prevalence of anxiety disorders increases with disease progression (26–38%) in persons living with HIV and AIDS (PLWHA).3 Chandra PS et al study showed 36% scored above cutoff on HDRS soon after diagnosis revelation.4 Kelly et al found that about one third of their patients met post-traumatic stress disorder criteria post-diagnosis.5 Morrison et al found significant anxiety difference between seropositive and seronegative women.6

While Chandra et al in their study found 40% depressed, 90% of them had comorbid anxiety disorder, 20% suicidal ideation, and 8% had attempted suicide.4 Morrison et al study revealed four times more frequent depression in seropositive (19.4%) vs seronegative women (4.8%), associated with older age, lower education, and substance abuse.6

In a study on 322 PLWHA, Komiti et al showed that 22% met criteria for major depressive disorder, with drug history and stress predicting depression, while relationships were protective.7 Psychological distress correlates with reduced helper T-cells and B-cells.8 Higher rates in women stem from caregiver burden, stigma, and poor care. Secondary mania had a prevalence is 1.2% in HIV positive status and 4.3% in AIDS; about half of them showed neuroradiological abnormalities, and one third developed cognitive impairment.9

Sewell et al revealed those with psychotic symptoms had greater neurocognitive impairment – 100% in delusions, and 60% and 45% in auditory and visual hallucinations respectively.10 New-onset incidence of psychosis is 0.2–15% in studies by Navia et al, and others.11 The study by Robertson et al showed one third having current suicidal ideation, and two thirds with lifetime ideation12 (18.2% current in study).

Antiretroviral drugs interact with psychotropics. PIs/NNRTIs alter CYP450 activity. Fluoxetine use along with ritonavir, efavirenz or saquinavir risks serotonin syndrome. Valproic acid though safe may increase viral replication.13 Carbamazepine levels increase with ritonavir via CYP3A4 inhibition. PLWHA are sensitive to EPS.14 With clozapine, ritonavir increases the risk of agranulocytosis, and with risperidone it increases risk of extrapyramidal side effects and neuroleptic malignant syndrome.

It is a cross-sectional study with the objective to assess the prevalence of psychiatric co-morbidity in people aged 18-65 years who were diagnosed as HIV positive and on treatment at the ART Centre at Mahatma Gandhi Memorial Hospital, Trichy. Individuals with severe cognitive impairment or other physical illnesses, and those with a past history of mental illness were excluded. Following approval obtained from Institutional Ethical Committee (IEC-KAPVGMC-45/17), selection of 100 individuals was done by random sampling method.

The nature of the study was explained to the patients, and informed consent was obtained. Patients were interviewed and socio demographic details were collected as per proforma. Prevalence of depression and other psychiatric co- morbidities in people living with HIV & AIDS was evaluated based on ICD–10 (International Classification of Diseases) Clinical and Diagnostic Criteria.

Depression severity was assessed using Hamilton Depression Rating Scale (HDRS).15 With 17 items it has a high inter-rater reliability (0.80-0.98) for total scores, and validity (0.65-0.90). While scores can range from 0 to 54, a total of 7-17 indicate mild depression, 18-24 moderate depression and >24 severe depression.

Brief Psychiatric Rating Scale was also applied to all patients. Developed by Overall and Gorham, the Brief Psychiatric Rating Scale (BPRS) the most frequently used instruments for evaluating psychopathology, is an 18 item scale, rated on a seven-point likert scale from 0 to 7, with total score ranging from 18 to 126. Scores are interpreted as: 25 – 30 borderline; 31 – 40 mildly affected; 41 – 53  moderately affected; > 54 considerably affected. The inter-rater reliabilities for the BPRS between 0.87 and 0.97 have been reported.16  The results were statistically analyzed using SPSS software and conclusion arrived at this.

Mean age was 41.4 years, and mean duration of illness was 7 years. Majority of the patients (67%) were between 31 and 50 years of age, and 54% were female (table 1). Majority had studied either middle or high school (57%), and were skilled or semi-skilled workers (91%). About 70% of the study population belongs to upper lower class of socioeconomic status, and about 57% of patients were married. Among the study population, about two thirds(64%) were living in a nuclear family.

Prevalence of psychiatric morbidity among HIV/AIDS patients was 33%(table 2) in which majority of patients found to have depressive disorder(12%). Next comes substance and stress related disorders with 6% each. 

Depressive disorder (14.8% of females vs 8.7% of males) and stress related disorder (9.3% vs 2.2%) were more prevalent in females(table 3) whereas substance related disorders were seen more in males(10.9%). Non-organic insomnia and anxiety disorder were both present in males and females moreover equally (4+.3%). About half of people above 50 years of age were seen to have some psychiatric morbidity compared to people between 18 to 30 years of age who have least frequency of any psychiatric morbidity(15.4%). About two thirds of substance related disorder were between the age group 31 and 40 years. Depressive and stress-related disorders were equally spread over the age group of 30 to 60 years. Non organic insomnia was present in all age groups. Stress related disorders were present in patients of age between 30 and 60 years. Anxiety is seen more in the age group of 41 to 60 years. These differences were not statistically significant.

The psychiatric morbidity was less seen in middle and lower middle class, while substance related disorder, depressive disorder, stress related disorder and non-organic insomnia were mostly seen in patients who belong to upper lower socioeconomic (SE) status. In our study, on distributing the psychiatric morbidity with respect to socio economic status, substance related disorder (83%) was found to be high in lower socioeconomic class. Mood disorder (67%) was present in more number in lower SE class. Stress related disorders were present only in lower SE class. Married people have slightly less morbidity compared to the singles, and the latter were more frequently depressed.

Psychiatric illnesses were more frequent in unskilled workers especially stress-related and depressive disorders. Substance-related disorders were found only among semi-skilled (33%) and skilled workers (67%). Stress-related disorders were found higher among semi-skilled (50%) and unskilled workers (33%). Over 68% of mood disorders and 75% of non-organic insomnia diagnoses were also found higher among semi-skilled workers. Psychiatric morbidities were seen more in people living in nuclear family. However these differences were not statistically significant. 

Statistical significance was found in the distribution of psychiatric illnesses with respect to education. Psychiatric illnesses were seen more among people with degrees and diplomas. Substance use disorder was the most among those without any formal education and people with primary school education. Anxiety disorders were found higher in patients with high school education (75%).

Prevalence of depressive disorders were found to be 12%, and among them two-thirds were females. The patients with mood disorders were above the age of 30 yrs. Regarding the educational status, mood disorders were seen to be higher in number (92%) in patients with high school education or less. It was found to be higher in patients who were semi-skilled workers (68%) by occupation. While considering the socio-economic status, it was found to be higher (67%) in patients who belong to lower socio-economic status than middle socio-economic status. Among widow/ widower and divorced/ separated patients, mood disorders were present in higher percentage compared to other psychiatric morbidities (about 18 and 22%). About 75% of those with mood disorders were living in nuclear family.

 The mean CD4 count of the study population was found to be 666.69 +295.31 (table 4). The minimum CD4 count was found to be 101 and maximum to be 1525. On analyzing the duration of HIV illness mean was found to be 7.11+5.67 years, with a range from one week to 27 years.

 On administering BPRS among the sample subjects, 81% were found to be normal, 17% scored in the borderline level and only 2% were found to have mild psychosis. The minimum BPRS score was 18 and maximum score recorded was 31(table 5). The mean BPRS score was 22.17+3.19. The mean BPRS scores were 21.63 and 22.63 in males and females respectively. HDRS scores revealed that among 12 depressive patients, 8 scored in the mild level, 3 in the moderate level and one in the severe level(table 2). 

Interaction between psychiatric morbidity, and duration of illness, CD4 count and BPRS:

Psychiatry morbidities like stress-related and substance use disorders were more in the initial five years, and probably partially improved with continued HIV treatment and psychoeducation, and gradual rise in confidence over time (table 6).  But depression and anxiety disorders were common with longer duration of illness (mean of 9 and 12 years respectively, compared to 7 years in the no-morbidity group). The mean CD4 count of patients without psychiatric illness was 774.84+260.89 whereas the mean CD4 count of patients with psychiatric illness was lower, and the least in psychosis. This difference is found to be statistically significant. High BPRS scores are seen in patients with psychosis, substance-related disorders and depressive disorder as expected, and 3% of those without any morbidity had borderline scores.

Various psychiatric illnesses were associated with decrease in CD4 count, longer duration of HIV illness and increased BPRS scores. These associations were found to be statistically significant.

PLWHA with low CD4 count were found to have high BPRS scores (table 7). The mean CD4 count was 723.43+285.34 for those who scored normal in BPRS scale. The mean CD4 count was 443.94+199.77 for those who scored in the borderline level. The mean CD4 count was 262.00+223.44 for those who scored in the mild level. This association was found to be statistically significant. CD4 count and duration of HIV illness varied significantly with different BPRS levels.

The mean duration of illness in years for those who scored normal in BPRS scores was the highest – 7.2085+5.27 years, 6.94+7.56 for those who scored in the borderline level, and 5.00+5.65 for those who scored in the mild level. These results were found to be statistically significant.

Table 1: Sociodemographic variables in HIV/AIDS patients (N = 100)

Table 2: Brief Psychiatric Rating Scale (BPRS) scores and psychiatric morbidity among HIV/AIDS patients

Table 3: Distribution of psychiatric morbidities among various sociodemographic variables.

Table 4: Correlation between CD4 count and BPRS scores among HIV/AIDS patients

** Correlation is significant at the 0.01 level.

Table 5: Descriptive statistics of age, income, duration of HIV illness, BPRS scores and CD4 count

Table 6: Relationship between psychiatric morbidity and CD4 count, duration of HIV illness and BPRS scores

Statistical test: One-way ANOVA.

Table 7: Association of BPRS score with CD4 count and duration of HIV illness

Statistical test: One-way ANOVA.

The aim of the study was to assess the prevalence of psychiatric morbidity and specifically assess the prevalence and severity of depression in people living with HIV/AIDS.

Relationship between psychiatric morbidity and various sociodemographic variables was also studied. The association of CD4 count and duration of HIV illness with psychiatric morbidity was also assessed.

The socio demographic variables studied include age, sex, education, occupation, socioeconomic status, marital status, living arrangement and area of residence. More than two thirds of patients were between 31 and 50 years of age. Around 55% were semi-skilled workers by occupation, 70% belonged to upper lower socioeconomic class, 57% were living with spouse, and 64% were living in a nuclear family.

The prevalence of psychiatric morbidity was found to be higher in people living with HIV/AIDS compared to general population. It was also found to be higher when compared to Jacob et al¹⁷ who conducted among 50 homosexual men (26.1%), whereas a study by Deshpande et al showed a prevalence of 34%.¹⁸ Presence of psychiatric morbidity can increase the disease progression and hamper drug compliance leading to increased morbidity and affect their quality of life.

In this study, the prevalence of depressive disorder was found to be 12% which is lower when compared to Chandra et al⁴ who found 40% of HIV patients suffering from depression. This may be because of the improved awareness, social acceptance and newer antiretroviral regimens would have improved their life quality than in the past decade. On comparing with the study done by Morrison,⁶ the prevalence of mood disorder was found to be slightly lower. In their study the prevalence was 19.4% which included only women. The prevalence in our study was found to be lower compared to the study done by Komiti et al,⁷ and other studies. Frequency of depression was 16.1% in the study by Alvi et al¹⁹ where total sample size was 434. Among them 82% were mild in severity. About 30% were depressed in the study by Algoodkar et al²⁰ who used ICD10 checklist for 100 clinically stable clients with CD4>400. It was 19.3% in the study by Patel et al.²¹ In the study on 100 PLWHA by Nebhinani et al²² when compared to rheumatoid arthritis(RA) group, 45% (vs 60%, p=0.021) were diagnosable with a psychiatric diagnosis using DSM-IV. Frequency of major depressive disorder was 19% (vs 45% in RA).

Anxiety disorder prevalence was found to be between 2 and 38% in other literatures. In this study, it was found to be 4.0% which is less when compared with Chandra et al,⁴ whose study showed 36% of patients having anxiety disorder. As that study was done in patients as soon as revelation of HIV status the high prevalence was as expected. Prevalence of PTSD was found to be about one third in the study done by Kelly et al.⁵ But in our study PTSD was not found in the study population. The anxiety prevalence in this study is similar to the study done by Morrison et al.⁶

Mood and stress-related disorders were more seen in females whereas substance related disorders were more seen in males. Prevalence of psychiatric comorbidity was found to be 50% in patients above the age of 50 years. Substance-related disorders were more prevalent in the thirties, and only in patients who had primary and middle school education. Anxiety disorders were found higher in patients with high school education (75%). Psychiatric morbidity was found to be lower (26.7%) in patients who were skilled workers. Mood disorders, substance and stress-related disorders were found to be high in lower socioeconomic class. Psychiatric morbidity was found to be lower in married people.

In our study, among the depressed, two-thirds were females, like the Algoodkar et al study where female gender (75% vs 23%), and lack of family support (50%) were the variables with significantly more depression.²⁰ About 75% of those with mood disorders were living in nuclear family in our study. Among widow/widower and divorced/separated patients, mood disorders were present in higher frequencies, in contrast to the 31.3% having depression among those living with spouses and the 27.3% in the unmarried/separated group in Algoodkar et al study.

The BPRS scores were normal in 81% of patients. BPRS scores were higher in patients with less duration of HIV illness. The BPRS scores were found to have a negative correlation with CD4 count and this was found to be statistically significant.

On Hamilton depression rating scale, 67% of the patients with depressive disorders scored in the mild level. Algoodkar et al²⁰ found a significantly higher mean severity (MADRS) score of 19.3 in the depressed HIV group (vs 3.7 in the non-depressed group). Severity of depression scores (HDRS) significantly correlated with decreased CD4 (r=0.2142) in the Patel et al study.²¹

The mean CD4 count of the study population was found to be 666.69+295.31. Average CD4 was 384.6(+179.6) cells per cu.mm in the Alvi et al study,¹⁹ and about 32.3% of those with CD4<200 had depression significantly compared to 14.2% in CD4>200 group. Those with CD4<200 were found with 2.6 times more occurrence of depression in multivariate analysis (aOR 2.630, 95% CI: 1.29-5.33, p0.007). Depression increased with decreasing CD4 (p=0.016) in the study by Patel et al.²¹ CD4 was found not significantly associated with depression with a mean of 604+200 (vs 590.5+178.7 in the non-depressed) in the study by Algoodkar et al.²⁰ The mean CD4 count of patients with psychiatric illnesses was lower than those without them in this study (table ).

Severity of clinical staging was associated with increased frequency (91.64%) of HIV-Associated Neurocognitive Disorders (HAND) and organic affective symptoms.²⁴

As duration of HIV illness increased, frequency of depression and anxiety disorders increased in our study. Longer duration since HIV diagnosis (aOR: 1.05, 95% CI: 1.01-1.12), and overall awareness of health status (aOR: 0.96, 95% CI: 0.93-0.99), were associated rising depressive features.²⁵ About 26.3% of those in early years of HIV diagnosis and treatment had depression, compared to 30.9% of those with more than 3 years of ART, though non-significant in the study by Algoodkar.²⁰

But in the study by Alvi et al,¹⁹ those with less than five years duration since HIV diagnosis had increased frequency of depression (18.7%, vs 10.7% in others). This was affirmed with an aOR of 1.657 in multivariate analysis, but was not significant. No difference was found whether HIV status was disclosed or otherwise. Also as per the statistical analysis of Chacko et al, longer total duration since HIV diagnosis is negatively associated with progressive HAND events, 65% in >10 years group compared to 80% in <10 years group.²⁴ Though almost equal distribution (about 20-25% samples) was in each clinical stages of the disease, increased duration of HIV illness was observed in 59% of cases.

Low CD4 counts were associated with high BPRS scores. The mean CD4 count was the highest – 723.43 for patients who scored normal in BPRS scale. Mello et al in their study found current major depression in 25.8% and lifetime prevalence in 60%, and positively associated with duration of illness in univariate analysis, and with higher viral loads and lack of emotional support in multivariate analysis.²⁶ 

In this study of 100 patients, it was found that the prevalence of psychiatric morbidity was high in people living with HIV/AIDS and mood disorder was more common among them. Females had higher prevalence of mood disorder. Psychiatric morbidity was found to have association with educational status. Lower CD4 count and longer duration of HIV illness also had an association with psychiatric morbidity.

The ultimate goal for treatment is not only to promote longevity but also to enhance the quality of life(QOL) by regular screening and treating psychiatric morbidities. Strategies developed to foster communication with a good healthcare support system, especially for women, may result in potentially higher QOL outcomes. Facilitating access to care including mental health for all HIV/AIDS patients should be made a priority. 

Limitations

The study results cannot be generalized to the whole community since the sample size was small. It was a cross-sectional study, and the possibility of pre-existing psychiatric illness prior to the contract of HIV illness could not be decisively ruled out. Influence of antiretroviral therapy on psychiatric morbidity was not assessed in this study. The correlation between severity of HIV/AIDS illness, psychiatric morbidities and quality of life was not studied.

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