Depression in HIV Positives under ART in TUTH Clinic : A Cross-Sectional Study

Introduction: Among PLWHA, most studies have reported a high prevalence (20-37%) of depression, which negatively impacts the adherence to ART, and leads to increased morbidity and mortality. Objective: This study aims to study depression among PLWHA who were under ART in the out-patient HIV clinic Method: This study was conducted at the outpatient HIV clinic in a tertiary center (TUTH). All relevant information were noted in a semistructured proforma designed for the study. BDI-II and ICD-10 DCR were the tools used. Result: Out of total 99 patients, 34 were depressed (34.2%), moderate depression with somatic syndrome category being the majority (19, 19.2%) (p< 0.05). Depression was significantly associated with low family income, alcohol use and past history of depression. Conclusion: Depression was found to be highly prevalent in PLWHA who were under ART.


INTRODUCTION
HIV may lead to depression via the psychological reaction of having acquired the illness, sub-cortical injury by the virus, opportunistic infections occurring in the AIDS, side effects of ART, and others.Depression may make an individual vulnerable to acquiring HIV, because those depressed often make maladaptive or inappropriate choices like unsafe sexual practices and drug abuse.Depression further is associated with high morbidity and mortality, particularly due to impaired adherence to ART. 1,2 However, depression is under-recognized, under-diagnosed and undertreated, so screening for depression should be attempted regularly, especially at the time of diagnosis and before initiating HAART 3,4 Most western studies report the prevalence of depression in PLWHA as 2-3 times more than in the general population.Especially, studies after 1996, reported elevated rates of depression. 5ost African studies from report point prevalence of MDD between 3-54%. 6In a Chinese study, almost 79% (n = 22) of HIV+ but just 4% (n = 1) of HIV− groups reported lifetime major depression.Of the 22 HIV+ individuals with lifetime MDD, only one had onset before learning of HIV status.The remainder developed MDD within 6 months after testing HIV positive. 7Few studies in India 6,8 report the variable range 8-37%, reflecting differences in sample characteristics, methodology, study setting, operational definition of depression, and other factors.A community based crosssectional study of 322 adult PLWHA in the Kathmandu valley, reported 25.5% to have BDIdefined depression. 9An specialty HIV clinic at a tertiary care centre of South India reported syndromal depression in 40 percent of seropositive individuals.Severity of depressive symptoms was related to abuse or dependence on alcohol (47%), and poor social support (43%) 8 This study was an attempt to study depression in PLWHA under ART in an out-patient clinic in TUTH, a tertiary centre hospital of this country located in the capital city, Kathmandu.Our hypothesis was that the prevalence of depression would replicate most of the earlier studies.

MATERIAL AND METHOD Study Design and subjects
A descriptive cross-sectional study was conducted among HIV positive patients under ART in a TUTH clinic with the aim of studying depression for the 1-year-period (October, 2013 to September, 2014).A total (N) of 99 subjects were included based on strict criteria for inclusion (age 18-60 yrs; on ART for at least 6 months) and exclusion (speech disorder; mental retardation; delirium; dementia; serious medical illnesses like COPD, heart diseases, renal failure)

Procedure
The semi-structured proforma was filled with adequate information, the history taken from patients and informants.The clinical diagnosis was made after the Mental State Examination.

Beck Depression Inventory (BDI-II) was used for comparison with the clinical diagnosis of depression. The diagnosis of depression was confirmed by ICD-10 classification of Mental and Behavioral Disorders-Diagnostic Criteria for
Research (WHO-1992) in patients after thorough discussion with consultant psychiatrists who were available on their respective OPD days.The socio-demographic information, the clinical medical information as well as information regarding HIV parameters were obtained by the principal researcher from the patients' medical records in the HIV clinic.Finally, all the data were analyzed by using suitable statistical tools.

Statistical tools
Data were analyzed using SPSS version 16 (Chicago, Illinois, USA).Descriptive analysis was performed, and mean, median, range were calculated.The data were explained as mean± standard deviation (SD) wherever suitable.Spearman's rank correlation was performed for ordinal dataset.Chi-square tests were applied for categorical data.Independent sample t test, ANOVA tests were applied wherever applicable.P-value of <0.05 was considered significant.

RESULT
The major results of the study have been depicted in the following tables after which a brief discussion is attempted.
imilar to previous studies 11,12 our study showed that majority (n=36, 36.4%)belonged to age group 30-39 yrs.In our study, the males (n=49, 49.5%) and the females (n=50, 50.5%) were almost equal in number, which can be counted for one of the strengths of the study.This coincidental occurrence during the purposive random sampling can be explained by the fact that most females had acquired HIV by heterosexual transmission from their husbands who were also under ART in the same HIV clinic.The maximum number of patients were married (n=69, 69.7%).The maximum number of patients educated were upto primary level (n=47, 47.5%),The majority were housewives (n=46, 46.5%); while unemployed were 13 (13.1%),thus implying that those not having specific paid jobs were around 60% (59/99=n/N).Our finding matches the finding of some previous studies that unemployment is associated with depression among PLWHA. 3,12,4n our study, patients from the Kathmandu valley (kathmandu, lalitpur, bhaktapur) were 57(57.5%),while those from outside the valley were 42(42.4%).This comparable number of patients from within and outside the valley could be due to our site being the tertiary referral center.Our finding shows that majority were Hindus (n=83, 83%), belonged to joint family (n=41, 41.4%) with total family income between Rs. 5000-10,000.
Our finding shows that most patients (n=85, 85.9%) had no past history of affective disorder.
Our results show significant association (X2=0.000)between current depression and past history of depression.Past history of depressive disorder is a major risk factor for current affective disorder, which like in other studies, has not been controlled for (limitation) in this study, and may be the reason for the high prevalence of depression in HIV positives.Our results show that majority (n=88, 88.9%) had no family history of depressive disorder.Though family history of depressive disorder was not controlled for (limitation of the study), majority had none, which gives more weight to our finding of depression among HIV positives.
Previous study showed risk of depression to be associated with family history of depressive disorder among PLWHA. 10n our sample, most patients, took alcohol socially (n=78, 78.8%), and most (n=82, 82.8%) never used any addictive substance.This may be due to the fact that half the sample consisted of females, and mostly housewives.

Types and severity of depression:
Our results, in accordance with the prevailing literature, show that most patients (n=65, 65.7%) were not depressed, while 19 (19.2%) had moderate depression with somatic syndrome, 5 (5.1%) had moderate depression without somatic syndrome, 6 (6.1%) had mild depression, and 4 (4%) had severe depression without psychotic features.Our study showed more number of subjects moderately depressed than severely depressed which is consistent with previous studies 13,14,15 Clinical experience also shows that usually moderate to severely depressed patients seek help than mildly depressed.

Limitations
It was a cross-sectional study, so causality among associations could not be established.The sampling method was simple purposive.The researcher was not blind to the psychiatric diagnosis of depressive disorder.Normal controls were not used in the study.Past history and family history of affective disorder, which are risk factors for current affective disorder in the individuals, were not excluded in the study.Alcohol/substance use and other confounding factors could not be controlled for in this study.
The study can't be generalized on the national level, because although the site of study is a tertiary referral centre, the catchment area is the Central Development Region of the country.

CONCLUSION:
In our context, depression is highly prevalent among PLWHA.However, due to various reasons it may be too early to generalize it for the whole country.Nevertheless, the finding is consistent with most previous studies.The significant association between MDD and past history of depression was found.MDD was not significantly associated with other analysed variables. REFERENCES: