Associations among depression, suicidal behavior, and quality of life in patients with human immunodeficiency virus

Table 1 Studies that investigated using specific psychometric instruments the association between depression/suicidality and quality of life in human immunodeficiency virus patients

Ref.	Study design	Sample size	Follow-up	Psychometric instruments assessing MDD, suicidality, and quality of life	General fIndings	Limitations	Conclusion
Ogundipe et al[30]	Cross-sectional study	295 PLWHA (102 males and 153 females; mean age 37.3 ± 8.7 yr)	No	GSQ-28, BDI, and WHOQOL-BREF	Overall, 13.6% of PLWHA reported suicidal ideation. A significant association between suicidal ideation and being unmarried, poor medication adherence and altered quality of life has been reported. Unemployment, emotional distress, religion, HIV status non-disclosure and previous suicidal attempts were significant predictors of suicidal ideation among PLWHA	(1) The cross-sectional nature of the study; (2) Subjects have been not assessed for the presence of prior suicide attempts; (3) Participants have been not evaluated during a follow-up period	Suicide should be considered a major health issue in subjects with HIV infection. Specific psychosocial and clinical factors may be useful to identify PLWHA who are at-risk for suicide
Pompili et al[38]	Cross-sectional study	88 outpatients (71 men and 17 women; mean age 42.9 ± 10.3 yr)	No	GMDS, BHS, SHSS, TEMPS-A, and SF-36	More severe depression and hopelessness have been found between patients with a poorer HRQoL when compared to those with a higher HRQoL. Higher scores on all dimensions of the TEMPS-A were also reported in those with a poorer HRQoL relative to subjects with a higher HRQoL	(1) The small sample size; (2) The cross-sectional nature of the study; (3) Data on HIV severity, illness duration, or age of symptom onset were not collected; (4) Data were collected via self-report and not validated by psychiatric examinations	Patients with a poorer HRQoL were more likely to have depressive affective temperaments, depression and suicide risk than patients with higher HRQoL
Kinyanda et al[31]	Cross-sectional study	618 HIV outpatients (169 male, 449 female; mean age in the 25-44 age band)	No	M.I.N.I., coping style index derived by variables of the MAC, and International HIV Dementia Scale	Prevalence of MHS and life-time attempted suicides resulted 7.8% and 3.9%, respectively. After univariate analyses, female gender, food insecurity, increasing negative life events, high stress score, negative coping style, past psychiatric history, psychosocial impairment, diagnoses of PTSD, GAD, and MDD resulted associated with MHS. After multivariate analyses, only female gender, increasing negative life events, a previous psychiatric history, and MDD were independently associated with MHS	(1) The cross-sectional nature of the study; (2) the small number of subjects with some of the diagnosed psychiatric disorders; (3) the threshold as a cut-off point for MHS has been not validated in the African socio-cultural context; (4) the use of the “risk for suicidality” measure instead of “suicidality”	Both social and psychological stressors may act on previous and current psychiatric morbidities triggering suicidality
Lewis et al[32]	Cross-sectional study	62 HIV-positive women (mean age 35.7 ± 6.6 yr)	No	BDI-FS, MM of the Primary Care Evaluation of Mental Disorders, ADL, and SCQ	ADL and subjective questionnaire of cognitive functioning were useful instruments to measure depression in HIV-positive women	(1) The cross-sectional nature of the present data; (2) The small sample size which may limit the generalization of findings; (3) Participants have been not evaluated during a follow-up period; (4) the sample includes only women	Diagnosis of depression is of great importance, not only clinically, but also to ensure the judicious allocation of scarce medical resources in the regions worst affected by HIV
Lee et al[33]	Cross-sectional study	576 patients (503 male, 73 female; mean age 40.6 ± 9.3 yr) of which 71 were HIV positive, and 514 had hepatitis C	No	A semi-structured questionnaire assessing demographics, quality of life, HIV risk behavior, and psychiatric symptoms,and WHOQOL-BREF	Overall, 21.0% of the subjects reported anxiety, 27.2% depression, 32.7% memory loss, and 32.7% attempted suicide. Based on the main findings, HIV-negative heroin users were more likely to have sexual intercourse without condoms during the six previous months	(1) The sample may be not representative of the Taiwanese heroin users population; (2) It was not possible to validate whether patients replied the questions truthfully	No significant differences were found between the HIV-positive and HIV-negative patients on psychiatric symptoms or quality of life
Atkinson et al[34]	Cross-sectional study	203 HIV-infected former plasma donors and 198 HIV-negative donor controls (122 male, 279 female; mean age 40.2 ± 6.4 yr)	No	WMH-CIDI, BDI-II, MOS-HIV, Modified HIV Stressor Scale, ADL, and Social Support Scale	HIV+ subjects reported a significantly higher rate of lifetime MDD (14% vs 5%) than HIV- participants. Both HIV+ and HIV- reported similar rates of current MDD. HIV+ were more likely to have lifetime substance use diagnoses than HIV- (14% vs 6%). Importantly, worse daily functioning and life quality as well as unemployment were independently predicted by both depression and AIDS	(1) Rates of depression may be underestimated by the used psychometric measures; (2) Recurrence of MDD episodes and bipolar disorder cases have not been examined; (3) The sample is derived by an agrarian setting; (4) The preliminary nature of the findings	High lifetime rates of MDD and suicidality were found in this HIV-infected agrarian cohort presumably due to the existence of a pre-HIV mood disorder, direct effects of HIV, social stigma, negative impact of HIV/AIDS on employment together with the perception that HIV is a terminal condition
Sherr et al[11]	Cross-sectional study	778 HIV-positive clinic attenders (183 heterosexual women, 76 heterosexual men, 496 gay/bisexual; mean age 40.5 yr)	No	Suicidal ideation reported using a self-report item based on feelings in the preceding week, levels of optimism in relation to treatment and infectiousness, MSAS short-form, and EuroQol-5D	Suicidal ideation was reported by 31% of patients. Heterosexual men and black respondents were twice more likely to have suicidal ideation relative to gay men or women and White/Asian respondents, respectively. Also, those with lack of disclosure were twice more likely to have suicidal ideation than those without. Higher physical and psychological symptoms independently predicted suicidal ideation	(1) The cross-sectional study design; (2) Subjects have been not evaluated for the presence of previous suicide attempts; (3) Participants have been not tested during a follow-up period	Suicidal ideation rates among HIV-positive clinic attenders were high
Jin et al[35]	Cross-sectional study	28 HIV+ participants and 23 matched HIV- controls (38 male, 13 female; mean age 35.4 ± 6.7 yr)	No	CIDI Depression Module, BDI-I, Module E of the CIDI assessing lifetime suicidality, ADL	Overall, 79%of HIV-infected subjects had a lifetime rate of major depression relative to 4% of the comparison group. 9% of patients received treatment for depression, but 18% showed active suicidal thoughts. Worse daily functioning was independently predicted by both depression and HIV+ status	(1) The small sample size that may limit the generalization of the present findings; (2) The effects of gender could be not separated; (3) The sample was selected for feasibility purposes	High rates of major depression and suicidality have been found in HIV-infected Chinese subjects

ADL: Activities of daily living; BDI: Beck Depression Inventory; BHS: Beck Hopelessness Scale; BDI-FS: Beck Depression Inventory-Fast Screen for Medical Patients; CIDI Version 2.1: Composite International Diagnostic Interview Depression module; DDRS: Desire for Death Rating Scale; GAD: Generalised anxiety disorder; GSQ-28: General Health Questionnaire; GMDS: Gotland Male Depression Scale; HRQoL: Health-related quality of life; MDD: Major depressive disorder; M-QOL: McGill Quality of Life Questionnaire; MSAS: Memprial Symptom Assessment Schedule; MAC: Mental Adjustment to Cancer Scale; MM: Mood Module; MHS: Moderate to high risk for suicidality; MOS-HIV: Medical Outcomes Study-HIV; PLWHA: People living with HIV/AIDS; PTSD: Post-traumatic stress disorder; SAHD: Schedule of Attitudes toward Hastened Death; SF-36: Short-Form 36-Item Health Survey; SCQ: Subjective Complaints Questionnaire; SHSS: Suicidal History Self-Rating Screening Scale; TEMPS-A: Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire version; M.I.N.I.: The Mini-International Neuropsychiatric Interview; WHOQOL-BREF: World Health Organization Quality of Life Assessment-Brief Version; WMH-CIDI, version 3.0: World Mental Health Composite International Diagnostic Interview; HIV: Human immunodeficiency virus.