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.

Table 2 Studies that investigated without 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	Quality of life instruments	General findings	Limitations	Conclusion
Breitbart et al[39]	Follow-up study	372 patients with advanced AIDS, of which 42 were re-assessed at the follow-up (280 men, 92 female; mean age 44.4 ± 9.4 yr)	2-mo follow-up	Depression module of the SCID, HIV version, Ham-D, SAHD, DDRS, no specific psychometric instruments were used to measure quality of life	A significant association between desire for death and depression was found but desire for death was reduced in those patients who responded to antidepressants medications. However, approximately half of subjects who received antidepressant medications and/or supportive psychotherapy or counseling demonstrated little or no improvement in depressive symptoms	(1) The study was not a controlled clinical trial of antidepressant therapy; (2) Systematic bias (e.g., with more refractory patients being less likely to remain in the study) may be not excluded; (3) The failure to find significant differences about the proportion of patients with a high desire for hastened death may reflect the limited power of these analyses	Depressed patients who were successfully treated with antidepressant medications reported a significant reduction of desire for death
Haller et al[36]	Cross-sectional study	190 HIV patients (129 male, 61 female; mean age 37.3 ± 7.4 yr)	No	UM-CIDI, MCMI-III, Suicide Screener (seven-item structured interview), quality of life derived by HIV-PARSE	Overall, 26% of subjects reported suicide thoughts within 30 d of admission, 49% a suicide plan, and 48% a suicide intent. Individuals with suicidal ideation had predominantly MDD (64%), drug dependence (52%), and depressive personality disorder (50%). After regression analyses, those with MDD, dysthymia, substance abuse, thought disorder, PTSD, and borderline/avoidant personality disorders were more likely to have suicidality. Concerning the quality of life variables which were measured, leisure/social and family/friends were strongly associated with suicidal ideation	(1) The cross-sectional nature of the findings; (2) No specific psychometric instruments were used.	Subjects with substance use disorders, unstable interpersonal relations, and a restricted social environment may be considered at-risk individuals and need to be regularly screened for suicidality
Kalichman et al[37]	Cross-sectional study	113 HIV-AIDS subjects (mean age 53, age range 47-69)	No	Beck Depression Index, and WOC	Subjects who reported suicide thoughts (27%) have also higher emotional distress and poorer health-related quality of life relative to those who had not considered suicide. Furthermore, escape and avoidance were more frequently used whereas positive-reappraisal coping strategies were less frequently used by those with suicide thoughts. An association between suicide thoughts and the perception of reduced social support from friends and family was also reported. The mentioned differences remained even after controlling for symptoms of depression	(1) The small sample size; (2) The cross-sectional nature of the findings. These factors may limit the generalization of the findings	Relevant emotional distress and suicide thoughts were experienced by subjects in midlife and older individuals with HIV-AIDS
Krabbendam et al[40]	Cross-sectional study	24 HIV women (mean age 32 yr with a range of 20-49 yr)	No	In depth interviews using a qualitative semi-structured approach providing insights into feelings, perceptions, beliefs	Strong emotions and quality of life impairment were experienced by HIV-infected women directly after diagnosis. It has been suggested that one counseling session was not effective	(1) The small sample size and the cross-sectional nature of the findings may seriously limit the generalization of the present findings; (2) Counseling given once was reported to be not effective	Continuous counseling may be provided by support groups. Importantly, the counselors may be used as examples

DDRS: Desire for Death Rating Scale; SCID: Depression module of the Structured Clinical Interview for DSM-IV, HIV version; Ham-D: Hamilton Rating Scale for Depression; MDD: Major depressive disorder; MCMI: Millon Clinical Multiaxial Inventory; PTSD: Post-traumatic stress disorder; SAHD: Schedule of Attitudes toward Hastened Death; UM-CIDI: University of Michigan Composite International Diagnostic Interview; WOC: Ways of Coping Questionnaire; HIV: Human immunodeficiency virus.