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. Author manuscript; available in PMC: 2024 Jan 13.
Published in final edited form as: Afr J AIDS Res. 2023 Apr;22(1):54–62. doi: 10.2989/16085906.2023.2186252

Symptoms of depression, anxiety, and thoughts of suicide/self-injury in adolescents and young adults living with HIV in Botswana

Merrian Brooks 1,*, Barbara Burmen 2, Anthony Olashore 3, Alemayehu Mekonnen Gezmu 4, Keneilwe Molebatsi 3, Ontibile Tshume 5, Onkemetse Phoi 5, Knashawn Morales 7, Mogomotsi Matshaba 3,6, Tami Benton 8, Elizabeth D Lowenthal 9
PMCID: PMC10787227  NIHMSID: NIHMS1956878  PMID: 37116112

Abstract

Globally, mental health problems have been reported to be more common in youth living with HIV (YLWH) than in the general population, but routine mental health screening is rarely done in high-volume HIV clinics. In 2019, YLWH in a large HIV clinic in Botswana were screened using the Generalized Anxiety Scale-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) in a pilot standard-of-care screening programme. Two-way ANOVA was used to describe the effects of age group (12–<16, 16–<20 and 20–25 years old) and sex on GAD-7 and PHQ-9 scores. Chi-square statistics were used to compare characteristics of YLWH with and without potential suicidality/self-harm symptoms based on question 9 in the PHQ-9. Among 1 469 YLWH, 33.1%, 44.3% and 15.0% had anxiety, depression and potential suicidality/self-harm symptoms respectively. YLWH of 20–25 years old and 16–<20 years old had higher GAD-7 scores compared to 12–<16-year-olds (p = 0.014 and p = <0.001 respectively). Female YLWH of 20–25 years old had higher PHQ-9 scores compared to 12–<16-year-olds (p = 0.002). There were no other sex–age dynamics that were statistically significant. Female YLWH endorsed more thoughts of suicidality/self-harm than males (17% versus 13%, p = 0.03 respectively). Given the proportion of YLWH with mental health symptoms, Botswana should enhance investments in mental health services for YLWH, especially for young female adults who bear a disproportionate burden.

Keywords: adolescents and youth persons with HIV, symptoms of mental health disorders, resource-limited settings

Introduction

Mental health in all adolescents

Globally, 13% of 10–19-year-old adolescents experience some form of mental disorder with depression, anxiety and behavioural problems being the most common causes of morbidity and mortality in this population (World Health Organization, 2021). The World Health Organization indicates that the prevalence of anxiety among persons aged 10–14 years and 15–19 years is 3.6% and 4.6%, whereas the prevalence of depression is 1% and 2.8% respectively (World Health Organization, 2021). Recently, as shown in a systematic review from different countries, it has become clear that sub-Saharan African youth are deeply affected by mental illness, with one third to a half of youth showing symptoms of common mental disorders such as anxiety (25%), depression (12%–46%) and suicidal ideation (13–21%) (Jörns-Presentati et al., 2021).

Serious sequelae of common mental disorders such as death by suicide are also common. Suicide is the fourth leading cause of death among male adolescents aged 15 to 19 years and the third leading cause among females of the same age (UNICEF, n.d.; World Health Organization, n.d.). In 2019, the age-standardised suicide rate in Africa was 11.25 per 100 000 population (World Health Organization, 2019). The 2016 Botswana Youth Risk Behavioural Surveillance Survey (YRBSS) (where 9.6% self-reported a positive HIV status) showed that 22.4% of school-going 13–19-year-olds in Botswana had thought about committing suicide in the 12 months preceding the interview, with 22.3% having planned to commit suicide and 19.4% having attempted suicide (Republic of Botswana, 2016b). Similar results have been found among youth in other African countries. The rates of suicidality in Uganda ranged from 7.7% to 14% in the six months’ or one month preceding the assessment date; 13% to 21% of youth in Rwanda expressed suicidal ideation and behaviour and ideation and in South Africa, 5% and 24% of youth displayed suicidal behaviour and attempts, respectively (Jörns-Presentati, 2021).

Mental health disorders among YLWH

People living with HIV (PLWH) are known to have higher rates of neuropsychiatric illnesses, including poor cognitive function, substance use and mood disorders, than the general population (Remien, 2019). These may be related to the combination of HIV’s effects on the brain, side effects of antiretroviral medicines and social determinants such as stigma, isolation and poverty (Mellins & Malee, 2013). In Botswana, HIV prevalence ranges from 1.6%–2.7% and 2.7%–6.7% among male and female 15–24-year-old persons (Republic of Botswana, 2021) and the incidence among persons aged 16 to 24 years is the highest of all age groups in Botswana (Ussery, 2022). Among these adolescents in Botswana, poor HIV medication adherence has been shown to be associated with psychosocial dysfunction, contributing to repeating cycles of physical and mental illness in this vulnerable group (Lowenthal et al., 2012; Yang et al., 2018).

The global prevalence of anxiety and depressive disorders in YLWH is as high as 48.2% and 44.0% respectively (Too et al., 2021). Among adolescents living with HIV in Africa, the pooled prevalence of any psychiatric disorder is 27% (Dessauvagie et al., 2020; Olashore et al., 2021). Suicide is ranked among the top 10 causes of death among adolescents aged 10 to 19 years in Africa and globally, and suicidal ideation was found to be up to one in two in a small sample of university students with a mean age of 20 years in Botswana (Korb & Plattner, 2014). In Botswana, 9–12% of PLHIV had suicidal ideation (Lawler et al., 2011).

Screening and management of mental health disorders

There are routinised standardised screening procedures for tuberculosis (TB), respiratory tract infections and cervical cancer for those being monitored for HIV (Republic of Botswana, 2016a). Generally, however, routine screening for mental health disorders does not occur in HIV clinical care in resource-limited settings (Yemeke et al., 2020). In the absence of screening and timely diagnosis, untreated anxiety and depression contribute to poor health outcomes overall.

Untreated anxiety and depression can impair executive functioning, cognition and reality testing, promoting sexual indiscretion with the potential of increased HIV transmission (Bere et al., 2017). With HIV, there is also an association between mental illness and poor HIV medication adherence (Yang et al., 2018). Going into adulthood, mood disorders are associated with other long-term inflammatory diseases (Skovlund et al., 2016) such as heart (Lopez-Candales et al., 2017) and kidney disease (Silverstein, 2009), which can decrease overall quality and length of life. Given the positive advances made in HIV treatment, this would be a particularly devastating outcome (Benton et al., 2019).

Objective

Infectious disease clinics serving YLWH need to understand the overall burden of mental illness in their populations to expand the meaning of “comprehensive HIV care” to include comorbid mental illness, like the incorporation of TB into HIV care earlier in the epidemic. In this study, we assessed the prevalence of symptoms of anxiety and depression and suicidality/self-harm in a large cohort of youth aged 12 to 25 years living with HIV from a referral clinic in Gaborone, Botswana. We used clinically relevant, commonly used scales to better understand the mental health service needs of YLWH in low- and middle-income (LMIC) settings.

Methods

Study design and setting

The study is a data analysis of a mental health screening programme that was a pilot quality improvement project implemented at Botswana Baylor Children’s Clinical Centre of Excellence clinic in Gaborone, Botswana, between 1 January 2019 and 31 December 2019. Botswana Baylor Children’s Clinical Centre of Excellence, which was launched in June 2003, had an active patient enrolment of approximately 2 426 participants at the time of the inception of this study. This secondary data analysis was approved by the Botswana national institutional review board (IRB), The Botswana Baylor Children’s Clinical Centre of Excellence IRB and the University of Pennsylvania IRB.

Study population

Youth aged 12 to 25 years who had not undergone screening for symptoms of anxiety and depression within the 12 months preceding the study date and who were visiting the clinic for routine monitoring and/or medication refills during the study period were included. Youth who were screened within the 12 months preceding the intervention period were ineligible for screening. Participants were able to “opt out” of this routine screening process for symptoms of mental health disorders.

Screening tools

Data were extracted from the clinics mental health screening programme database. We extracted scores from the Generalized Anxiety Scale-7 (GAD-7) (Mossman et al., 2017) and the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001; Löwe et al., 2008; Keum et al., 2018) for this study. Both the GAD-7 and PHQ-9 are used to screen for symptoms of anxiety and depression that would warrant further inquiry.

The GAD-7 has questions related to symptoms that would be associated with a diagnosis of generalised anxiety disease: feeling nervous or anxious or on edge, being unable to stop/control worrying, worrying too much about different things, trouble relaxing, being so restless that it is hard to sit still, becoming easily annoyed or irritable and feeing afraid as if something awful could happen. It was possible to attain a minimum score of zero and a maximum score of 21, depending on frequency of symptoms over the past two weeks. Scores were interpreted as no/minimal anxiety (<5), mild anxiety (5–9), moderate anxiety (10–14) and severe anxiety symptoms (15–21) (Spitzer et al., 2006; Mossman et al., 2017).

The PHQ-9 has questions related to the symptoms of major depressive disorder, including interest or pleasure in doing things, feeling down or depressed or hopeless, problems sleeping, feeling tired or unenergetic, eating problems, feeling bad about oneself, moving too slowly or being fidgety and feeling that you would be better off dead. There is a minimum score of zero and a maximum score of 27 based on the frequency of symptoms over the previous two weeks. Scores were interpreted as no/minimal depression (<5), mild depression (5–14), moderate depression (5–14), moderately severe depression (15–19) and severe depression symptoms (20–27) (Kroenke et al., 2001). The last question on the PHQ-9 was also used to assess for potential suicidality/self-harm. Any score of >0 (i.e. 1, 2, or 3) of the last question of the PHQ-9 was considered indicative of potential suicidal ideation or self-harm since these scores indicated having thoughts that you would be better off dead or have thoughts of hurting yourself in some way over several days, more than half the days, or nearly every day. The PHQ-9 questions’ dichotomised form called the mood module has been validated among youth in southern Africa (Cholera et al., 2014) and used in PLWH, including in Botswana (Tommasello et al., 2006; Lawler et al., 2011).

Data management and analysis

After the mental health screening data were extracted, the data were then exported into the Statistical Package for Social Sciences (SPSS) Version 27 software (IBM, Chicago) for analysis. Both the PHQ-9 and GAD-7 were assessed for reliability using Cronbach’s alpha. We analysed data for all youth who completed all questions on the surveys. Frequencies and measures of central tendency were used to assess for data completeness and distribution. Normally distributed data were summarised using means and standard deviations. Skewed data were summarised using medians and interquartile range (IQR). Proportions were used to summarise the number of participants reporting no/minimal, mild, moderate and severe anxiety symptoms, among all participants and among participants with anxiety (i.e. reporting any symptom of anxiety). Similarly, proportions were used to summarise the number of participants reporting no/minimal, mild, moderate, moderately severe and severe depression symptoms, among all participants and among participants with depression (i.e. reporting any symptom of depression).

A two-way ANOVA was conducted to compare the main effects of sex and different age groups as well as their interaction on PHQ-9 and GAD-7 scores. Post hoc pairwise comparisons were conducted for those variables with the statistically significant omnibus test. The significance level (p-value) was set at <0.05, and a Bonferroni correction to the type I error rate was applied to pairwise comparisons.

Proportions were also used to summarise the number of participants reporting symptoms of suicidal ideation. Chi square statistics and Fisher’s exact test were used to compare characteristics of participants expressing potential suicidal ideation or self-harm to those of participants who did not express potential suicidal ideation or self-harm.

Results

Participant selection

A total of 1 482 adolescents and youth were screened from 1 January to 31 December 2019. We excluded 13 who did not complete both screening evaluations (12 underwent screening for anxiety only and one for depression only) from our primary analysis, leaving 1 469 who were included in the final analysis.

Participant demographic characteristics

Of the 1 469 young people who underwent screening for both anxiety and depression, the slight majority (51.1%) were male and 16–<20 years old (51.8%) (Table 1).

Table 1:

Screening outcomes for anxiety symptoms using GAD-7 and depression symptoms using PHQ-9 for YPLV in Gaborone, Botswana, 2019 (N = 1 469)

Anxiety symptoms
Participant characteristics n (%) None n (%) Present n (%) p-value None n (%) Mild n (%) Moderate n (%) Moderately severe n (%) Severe n (%) p-value
976 (66.4) 493 (31.6) 976 (66.1) 331 (22.5) 120 (8.2) 42 (2.9)
Age group (years)
 12–<16 288 (19.6) 203 (70.5) 85 (29.5) 0.100 203 (70.5) 64 (22.2) 15 (5.2) 6 (2.1) 0.216
 16–<20 761 (51.8) 509 (66.9) 252 (33.1) 509 (66.9) 165 (21.7) 67 (8.8) 20 (2.6)
 20–25 420 (28.6) 264 (62.9) 156 (37.1) 264 (62.9) 102 (24.3) 38 (9.1) 16 (3.8)
Sex
 Female 719 (48.9) 470 (65.4) 249 (34.6) 0.3956 470 (65.4) 166 (23.1) 61 (8.5) 22 (3.1) 0.848
 Male 750 (51.1) 506 (67.5) 244 (32.5) 506 (67.5) 165 (22.0) 59 (7.9) 20 (2.3)
Depression symptoms
818 (55.7) 651 (44.3) 818 (55.7) 424 (28.9) (10.9) 53 (3.6) 13 (0.9)
Age group (years)
 12–<16 288 (19.6) 172 (59.7) 116 (40.3) 0.048 172 (59.7) 78 (27.1) 30 (10.4) 7 (2.4) 1 (0.4) 0.148
 16–<20 761 (51.8) 432 (56.8) 329 (43.2) 432 (56.8) 215 (28.2) 77 (10.1) 32 (4.2) 5 (0.7)
 20–25 420 (28.6) 214 (50.9) 206 (49.1) 214 (50.9) 131 (31.2) 54 (12.9) 14 (3.3) 7 (1.7)
Sex
 Female 719 (48.9) 382 (53.1) 337 (46.9) 0.054 382 (53.1) 206 (28.7) 89 (12.4) 34 (4.7) 8 (1.1) 0.041
 Male 750 (51.1) 436 (58.1) 314 (41.9) 436 (58.1) 218 (29.1) 72 (9.6) 19 (2.5) 5 (0.7)
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GAD-7 and PHQ-9 validation

The Cronbach’s alphas were 0.806 and 0.743 for the GAD-7 and the PHQ-9 respectively.

GAD-7 screening severity level, age and sex

A total of 31.6% of participants had symptoms of anxiety. Among all analysed young people, GAD-7 screening outcomes were mild anxiety (22.5%), moderate anxiety (8.2%) and severe anxiety symptoms (2.9%) (Table 1).

The proportion of participants who screened positive for anxiety symptoms increased with age; however, this did not attain statistical significance (p = 0.100) (Table 1). Simple main effects analysis showed that age group had a statistically significant effect on the GAD-7 score (p = 0.002). YLWH of 20–25 years old and those of 16–<20 years old had significantly higher rates of anxiety symptoms when compared to 12–<16-year-olds (p = 0.036, 95% CI −1.370, −0.030; p = <0.001, 95% CI −1.860, −0.380 respectively) (Table 2).

Table 2:

Pairwise comparisons of GAD-7 and PHQ-9 scores according to age groups for all YPLH, Botswana, 2019 (both male and female)

Age group (years) Reference group GAD-7 scores PHQ-9 scores p-value
Mean difference Lower bound Upper bound p-value Mean difference Lower bound Upper bound
12–<16 16–<20 −0.703 −1.370 −0.030 0.036 −0.573 −1.300 0.160 0.155
12–<16 20–25 −1.123 −1.860 −0.380 <0.001 −1.068 −1.870 −0.260 0.005
16–<20 20–25 −0.420 −1.010 0.170 0.215 −0.495 −1.140 0.150 0.166
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Bold = significant differences

A similar proportion of female participants reported anxiety symptoms when compared to male participants (34.6% versus 32.5%, p = 0.395 for female and male participants respectively). The breakdown of mild/moderate/severe symptoms is outlined in Table 1. The higher mean GAD-7 scores seen in female participants when compared to male participants (4.1±4.3 versus 3.8±3.9 respectively) were not significantly different (p = 0.065) (Table S1).

A two-way ANOVA to analyse the effect of age group and sex on the total GAD-7 score illustrated the absence of a statistically significant interaction between the age group and sex (p = 0.832) (data not shown).

Frequency of specific anxiety symptoms

The most reported anxiety symptoms by all participants screened (N = 1 469) were worrying too much about different things, becoming easily annoyed or irritated and not being able to stop or control crying, reported by 52%, 52% and 36% of all participants respectively. Of note, only 463 of all screened participants met the criteria for having mild, moderate or severe anxiety symptoms (GAD-7 ≥5). (Figure S1).

The most reported anxiety symptoms by only participants screening positive for anxiety symptoms (n = 493) were worrying too much about different things, becoming easily annoyed or irritated and not being able to stop or control crying, reported by 88%, 85% and 75% of participants (Figure S1).

The most reported anxiety symptoms by only participants screening positive for severe anxiety symptoms (n = 42) were worrying too much about different things, not being able to stop or control crying and feeling afraid as though something awful may happen, reported by and 100%, 100%, 98% and 93% of participants respectively. (Figure S1).

PHQ-9 screening severity level, age and sex

Symptoms of depression were found in 44.3% of participants. Among all analysed participants, PHQ-9 screening outcomes were mild depression (28.9%), moderate depression (10.9%), moderately severe depression (3.6%) and severe depression symptoms (0.9%) (Table 1).

The proportion of participants that screened positive for depression increased significantly with an increase in the age group (p = 0.048) (Table 2). The mean PHQ-9 scores also, increased with age group (Table S1). Simple main effects analysis showed that age group did have a statistically significant effect on the PHQ-9 score (p = 0.009) (data not shown). YLWH aged 20–25 years had significantly higher rates of symptoms of depression when compared to 12- to <16-year-olds (p = 0.005, 95% CI −1.870, −0.260) (Table 2).

The proportion of participants reporting depression symptoms did not differ by sex (46.9% versus 41.9%, p = 0.054 for female and male participants respectively). However, there was a significantly higher proportion of female participants who reported moderate, moderately severe and severe depression symptoms when compared to male participants (12.4% versus 9.6%, 4.7% versus 2.5% and 1.1% versus 0.7% for female and male participants respectively, p = 0.041) (Table 1). The mean PHQ-9 scores were significantly higher in female participants when compared to male participants (5.3±4.8 versus 4.7±5.2 respectively, p < 0.001) (Table S1).

A two-way ANOVA to analyse the effect of age group and sex on the total PHQ-9 score showed the association between age group and PHQ-9 scores did not differ by sex (p = 0.686) (data not shown).

Frequency of specific depression symptoms

Among all participants screened (N = 1 469), the most reported symptom was feeling tired or having little energy, poor appetite or overeating and trouble falling or staying asleep or sleeping too much, reported by 52%, 42% and 41% respectively. Notably, some of these participants who may have screened positive for single or multiple symptoms of depression may not have met the threshold for being categorised as having mild symptoms of depression (PHQ-9 ≥5) (Figure S2).

Among those who screened positive for depression (n = 651), the most reported symptoms were feeling tired or having little energy, trouble falling or staying asleep or sleeping too much and feeling down, depressed and hopeless, reported by 76%, 66% and 66% of participants respectively (Figure S2).

The most reported depression symptoms by only participants screening positive for moderately severe and severe depression symptoms (n = 66) were feeling tired or having little energy, trouble falling or staying asleep or sleeping too much, feeling down depressed or hopeless and trouble concentrating on things, reported by 94%, 94%, 94% and 94% of participants with moderately severe and severe depression symptoms respectively (Figure S2).

Participants reporting both anxiety and depression symptoms

A total of 409 (27.8%), participants reported both anxiety and depression symptoms, 242 (16.5%) reported depression symptoms alone and 84 (5.7%) reported anxiety symptoms alone. The remainder (n = 734; 50.0%) did not meet the threshold for mild symptoms of anxiety or depression.

Among those who reported both depression and anxiety symptoms (n = 409), 26 (6.4%) had both severe anxiety symptoms and moderately severe or severe depression symptoms, 16 (3.9%) had severe anxiety symptoms with mild and moderate symptoms of depression and 38 (9.3%) had moderately severe and severe depression symptoms with mild anxiety symptoms. The remainder (n = 329; 80.4%) had milder symptoms. A detailed analysis of these symptoms is shown in Table S2.

Screening outcomes for potential suicidal ideation or self-harm

The self-injury/suicide question (SI/SQ) was answered by 224 (15.0%) participants. 8.2% had such thoughts for several days in the two weeks preceding the interview, 3.4% for more than half the days preceding the interview and 3.6% nearly every day preceding the interview.

There was no statistical difference among the different age groups on the rate of those endorsing suicidality; however, more female than male participants reported suicidality (17.0% versus 13.0%; p = 0.026). These results concur with those of Olashore et al. (2022) which indicate that 18.9% of adolescents living with HIV had suicidal behaviour, with females having a six-times higher risk of displaying suicidal behaviour compared to males (Olashore, 2022). Of those endorsing suicidality, 60 (26.7%) and 31 (13.8%) were categorised as having “no symptoms of anxiety” and “no symptoms of depression” respectively, based on their total GAD-7 and PHQ-9 scores. A higher proportion of participants thought they would be better off dead or wished to hurt themselves with increasing severity levels of anxiety (p < 0.001) and depression (p < 0.001) (Table 3).

Table 3.

Screening outcomes for potential suicidal ideation and self-harm (Q9 on the PHQ-9) by sex and age group

Participant characteristics Screening outcome for potential suicidal ideation and self-harm p-value
Positive n (%) Negative n (%)
224 (15) 1245 (85)
Age group (years)
 12–<16 41 (14) 247 (84) 0.698
 16–<20 114 (15) 647 (85)
 20–25 69 (16) 351 (84)
Sex
 Male 99 (13) 651 (87) 0.026
 Female 125 (17) 594 (83)
Severity of depression
 Minimal/No symptoms 31 (4) 787 (96) <0.001
 Mild 69 (16) 355 (84)
 Moderate 73 (45) 88 (55)
 Moderately severe 39 (74) 14 (26)
 Severe 12 (92) 1 (8)
Severity of anxiety
 No symptoms 60 (6) 916 (93) <0.001
 Mild 87 (26) 244 (74)
 Moderate 49 (41) 71 (59)
 Severe 28 (67) 14 (33)
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Discussion

In this large cohort of YLWH, almost half had symptoms of at least mild depression or anxiety, or both. Not surprisingly, older YLWH were at highest risk (World Health Organization, 2021). A significant proportion of those with symptoms had both anxiety and depression symptoms. Importantly, a high proportion who endorsed suicidal ideation or self-harm did not reach thresholds to be defined as having mild anxiety or depression symptoms.

The prevalence of anxiety and depression in the present study is slightly higher than the pooled prevalence reported in the recent systematic review of African studies, which found 26% and 24% respectively (Olashore et al., 2021). This may have been due to the fact that our population was composed exclusively of YLWH or related to differences in the age groups included in our study versus in the systematic review. That review included children as young as 3 years old and no youth aged under 19 years old (Slogrove & Sohn, 2018). It included children diagnosed with and presenting with symptoms of mental illness using a variety of different measures. Rates of depression disorder symptoms in the present survey were slightly higher than Woollett and colleagues (2017), who reported a depression rate of 27% in a similar population using a diagnostic tool (Mini International Neuropsychiatric Interview Kid & Parent version) to screen, as opposed to the self-administered PHQ-9 screening tool (Woollett et al., 2017). Overall, our results are consistent with the smaller published studies (sample sizes 82–222) conducted on other YLWH in African countries which have shown 15 to 50% prevalence of mood disorders based on diagnostic rather than screening criteria (Musisi & Kinyanda, 2009; Bankole et al., 2017; Ashaba et al., 2018; Kemigisha et al., 2019).

Older adolescent and young adult women have higher rates of depression and anxiety than their young male counterparts (Olashore et al., 2021) and YLWH and those without these symptoms show an increase in mood disorders as they get older (UNICEF, n.d.; World Health Organization, n.d.). Notably, adolescent boys and young men are often missed by common screeners (Porche & Giorgianni, 2020) and indeed a reverse sex trend has been seen in adults with HIV in Botswana (Gupta et al., 2010). If this is the case, the small trends and insignificant sex differences may represent this discrepancy. Our study is in line with the known relationship between the two disorders where globally about 2 in 5 people with anxiety will also report depressive symptoms and vice versa (Kalin, 2020).

Exploring suicide or self-harm

Using the last question on the PHQ-9, 15% of YLWH reported potential suicidal ideation and self-harm. The rate of youth answering yes to the SI/SQ in our population are similar to those found in a number of other studies with smaller samples of adolescents in Africa where rates were between 10% and 17%, mostly using the MINI International Psychiatric Interview for Children and Adolescents Suicide questions MINI Kid-SD (Ashaba et al., 2018; Rukundo et al., 2020; Namuli et al., 2021). Slightly higher rates of suicidality were seen on the MINI Kid-SD, with 24% of 13–17-year-olds living with HIV in South Africa having suicidality (Woollett et al., 2017). However, in the only other study with a similar sample size to ours (N =1 058), Sherr et al. (2018) found that 4.1% of youth had suicidality on the MINI Kid-SD. The MINI Kid-SD is an interviewer-administered questionnaire and thus provides a more comprehensive assessment of suicidality and is more likely to yield more accurate results when compared to a single screening question on the PHQ-9 (Sheehan et al., 1998; Rukundo et al., 2020). Thus, our screening results show rates that are similar to smaller studies in African YLWH, but add some heterogeneity to the work done by Sherr and colleagues. There are clear limitations to assessing suicide using the SI/SQ questions; however, the similarity of our findings in a larger dataset to other youth populations in Africa with smaller samples is truly concerning. This initial screening prompts further exploration into serious sequelae of mental illness in YLWH.

Notably, several participants who screened negative for possible depression or anxiety also replies “yes” to the SI/SQ, suggesting that some patients who are classified as having no symptoms of anxiety or depression based on total GAD-7 or PHQ-9 scores might still present self-injurious thoughts or acts. Suicide and self-injury are complex and can be associated with mental illnesses other than depression and anxiety, life stressors/impulsivity, or chronic disease (Olashore et al., 2021). Suicidality in YLWH specifically may also be triggered by low socio-economic status, orphanhood (disproportionately affecting YLWH) and the unique challenges of HIV stigma and HIV wasting syndrome (Rukundo et al., 2020; Namuli et al., 2021).

Strengths

The strengths of this study are in its large sample size, its demographic delineations and its comprehensive assessment using two validated, clinically relevant, mental health symptom screening tools. It also includes depression, anxiety and suicide/self-injury, providing a granular analysis of what specific mental disorders might be affecting this population. It is also advanced by its setting in a large HIV referral clinic in a resource-limited setting that bears the brunt of the HIV burden among adolescents and young persons living with HIV. Furthermore, screening for mental health disorders is provided in a setting with existing routinised standardised screening procedures for other disease such as tuberculosis, respiratory tract infections and cervical cancer.

Limitations

There were some limitations mostly related to the screening measures. Firstly, they are designed to identify symptoms of depression and anxiety and would require confirmation using the gold standard of interviews by a mental health professional. The findings, however, are relevant, given that symptoms of anxiety or depression have been demonstrated to interfere with adherence to treatment and are associated with morbidity and mortality (Skovlund et al., 2016; Yang et al., 2018). Though the screening questions cannot diagnose depression and anxiety, they are correlated with commonly used diagnostic tools (Löwe et al., 2008; Lawler et al., 2011), indicating that the rates from our study warrant further exploration. Secondly, though cut-off points for clinically relevant mental illness are established using populations of youth throughout the world, these may also need to be adjusted (i.e. does a score of 5 on the PHQ-9 meaningfully correlate with impairment in this population?). Future validity testing will allow exploration of cultural and age-specific milieux for both the tools and the cut-off points in this population of mostly perinatally infected YLWH. Most youths in our sample had symptoms that when confirmed could be classified as mild to moderate depression or anxiety. When considering the impact of mild to moderate mental illness in youth, it is important to understand that symptoms of mental illness have a variety of trajectories (Chaiton et al., 2013; Shore et al., 2018; Xu et al., 2019; Fernández et al., 2022). Those with sustained high levels or low current but increasing levels are at risk for serious mental health morbidity and mortality from suicidal ideation, intentions and actions. So, even if the categories were clinically confirmed, the long-term implications would be uncertain without understanding the trajectory of the disease. Our findings are concerning in that older youth had the highest rates of both depression and anxiety, indicating potentially sustained symptoms. Further studies should understand these trajectories that are not well explored in LMIC and especially not among YLWH. Lastly, the screening programme was provided to YLWH in an urban setting and thus its results may not be generalisable to YLWH in rural settings.

Further limitations to this study include limited demographic and follow-up data for outcomes. Subsequent work will explore the major precipitants and social factors that might contribute to the depression, anxiety and suicidal or self-injury symptoms and follow these precipitants and the symptoms over time. There are also limitations to anonymous screening techniques such as those used in this study, particularly in younger adolescents or those with limited unidentified literacy concerns. Further work will explore these mental health outcomes prospectively and with diagnostic procedures.

Conclusions and recommendations

In Botswana, where resources to treat mental disorders are limited, only adolescents with severe disorders such as psychosis and suicidal behaviours are referred for mental health treatment or hospitalisation (Olashore et al., 2017). This practice leaves out key opportunities to provide services for those with milder symptoms and to prevent more detrimental outcomes. As mental health interventions expand to include more community-based interventions to disrupt worsening psychiatric illness, it is the perfect time to screen and identify youth with less severe psychiatric cases and connect them to services (Das et al., 2016; Bere et al., 2017) and provide mental health resources that include suicide-specific interventions. Another recommendation might be to enact universal psychosocial support models that would target all clinic youth with evidence-based interventions, specifically for mood disorders including depression and anxiety. Example interventions might include automatic assignment to group therapy, lay counsellor-based therapy, single session interventions, or social supports such as financial disbursements (Galagali & Brooks, 2020). There could be an additional layer of services that meet the needs of young women specifically to try and close the gap between male and female YLWH outcomes.

Supplementary Material

supplemental tables

Acknowledgement —

We thank the MoH/BBCCCOE for maintaining the cohort of YLWH and in-kind support of the project.

Footnotes

Online supplementary data for this article are available at https://doi.org/10.2989/16085906.2023.2186252

References

  1. Ashaba S, Cooper-Vince C, Maling S, Rukundo GZ, Akena D, & Tsai AC (2018). Internalized HIV stigma, bullying, major depressive disorder, and high-risk suicidality among HIV-positive adolescents in rural Uganda. Global Mental Health, 5, e22. 10.1017/gmh.2018.15 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bankole KO, Bakare MO, Edet BE, Igwe MN, Ewa AU, Bankole IA, & Olose EE (2017). Psychological complications associated with HIV/AIDS infection among children in South-South Nigeria, sub-Saharan Africa. Cogent Medicine, 4(1), 1372869. 10.1080/2331205X.2017.1372869 [DOI] [Google Scholar]
  3. Benton TD, Ng WYK, Leung D, Canetti A, & Karnik N (2019). Depression among youth living with HIV/AIDS. Child and Adolescent Psychiatric Clinics of North America, 28(3), 447–459. 10.1016/j.chc.2019.02.014 [DOI] [PubMed] [Google Scholar]
  4. Bere T, Nyamayaro P, Magidson JF, Chibanda D, Chingono A, Munjoma R, Macpherson K, Ndhlovu CE, O’Cleirigh C, Kidia K, Safren SA, & Abas M (2017). Cultural adaptation of a cognitive-behavioural intervention to improve adherence to antiretroviral therapy among people living with HIV/AIDS in Zimbabwe: Nzira Itsva. Journal of Health Psychology, 22(10), 1265–1276. 10.1177/1359105315626783 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Chaiton M, Contreras G, Brunet J, Sabiston CM, O’Loughlin E, Low NCP, Karp I, Barnett TA, & O’Loughlin J (2013). Heterogeneity of depressive symptom trajectories through adolescence: Predicting outcomes in young adulthood. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 22(2), 96–105. https://pubmed.ncbi.nlm.nih.gov/23667355 [PMC free article] [PubMed] [Google Scholar]
  6. Cholera R, Gaynes BN, Pence BW, Bassett J, Qangule N, Macphail C, Bernhardt S, Pettifor A, & Miller WC (2014). Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa. Journal of Affective Disorders, 167, 160–166. 10.1016/j.jad.2014.06.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Das JK, Salam RA, Lassi ZS, Khan MN, Mahmood W, Patel V, & Bhutta ZA (2016). Interventions for adolescent mental health: An overview of systematic reviews. Journal of Adolescent Health, 59(4s), S49–S60. 10.1016/j.jadohealth.2016.06.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Dessauvagie AS, Jörns-Presentati A, Napp A-K, Stein D, Jonker D, Breet E, Charles W, Swart RL, Lahti M, Suliman S, Jansen R, van den Heuvel LL, Seedat S, & Groen G (2020). The prevalence of mental health problems in sub-Saharan adolescents living with HIV: a systematic review. Global Mental Health, 7, e29. 10.1017/gmh.2020.18 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Fernández RS, Crivelli L, Guimet NM, Allegri RF, Picco S, & Pedreira ME (2022). Psychological distress and mental health trajectories during the COVID-19 pandemic in Argentina: a longitudinal study. Scientific Reports, 12(1), 5632. 10.1038/s41598-022-09663-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Galagali PM, & Brooks MJ (2020). Psychological care in low-resource settings for adolescents. Clinical Child Psychology and Psychiatry, 25(3), 698–711. 10.1177/1359104520929741 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Gupta R, Dandu M, Packel LJ, Rutherford GW, Leiter K, Phaladze NA, Korte FP, Iacopino V, & Weiser SD (2010). Depression and HIV in Botswana: A population-based study on gender-specific socioeconomic and behavioral correlates. PloS One, 5, e14252. 10.1371/journal.pone.0014252 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Jörns-Presentati A, Napp AK, Dessauvagie AS, Stein DJ, Jonker D, Breet E, Charles W, Swart RL, Lahti M, Suliman S, Jansen R, van den Heuvel LL, Seedat S, & Groen G (2021). The prevalence of mental health problems in sub-Saharan adolescents: A systematic review. PloS One, 16(5), e0251689. 10.1371/journal.pone.0251689 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Kalin NH (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365–367. 10.1176/appi.ajp.2020.20030305 [DOI] [PubMed] [Google Scholar]
  14. Kemigisha E, Zanoni B, Bruce K, Menjivar R, Kadengye D, Atwine D, & Rukundo GZ (2019). Prevalence of depressive symptoms and associated factors among adolescents living with HIV/AIDS in South Western Uganda. AIDS Care, 31(10), 1297–1303. 10.1080/09540121.2019.1566511 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Keum BT, Miller MJ, & Inkelas KK (2018). Testing the factor structure and measurement invariance of the PHQ-9 across racially diverse U.S. college students. Psychol Assess, 30(8), 1096–1106. 10.1037/pas0000550 [DOI] [PubMed] [Google Scholar]
  16. Korb I, & Plattner IE (2014). Suicide ideation and depression in university students in Botswana. Journal of Psychology in Africa, 24(5), 420–426. 10.1080/14330237.2014.997010 [DOI] [Google Scholar]
  17. Kroenke K, Spitzer RL, & Williams JB (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Lawler K, Mosepele M, Seloilwe E, Ratcliffe S, Steele K, Nthobatsang R, & Steenhoff A (2011). Depression among HIV-positive individuals in Botswana: a behavioral surveillance. AIDS and Behavior, 15(1), 204–208. 10.1007/s10461-009-9622-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Lopez-Candales A, Hernández Burgos PM, Hernandez-Suarez DF, & Harris D (2017). Linking chronic inflammation with cardiovascular disease: From normal aging to the metabolic syndrome. Journal of Nature and Science, 3(4), e341. https://pubmed.ncbi.nlm.nih.gov/28670620 [PMC free article] [PubMed] [Google Scholar]
  20. Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, & Herzberg PY (2008). Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Medical Care, 46(3), 266–274. 10.1097/MLR.0b013e318160d093 [DOI] [PubMed] [Google Scholar]
  21. Lowenthal E, Lawler K, Harari N, Moamogwe L, Masunge J, Masedi M, Matome B, Seloilwe E, & Gross R (2012). Rapid psychosocial function screening test identified treatment failure in HIV+ African youth. AIDS Care, 24(6), 722–727. 10.1080/09540121.2011.644233 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Mellins CA, & Malee KM (2013). Understanding the mental health of youth living with perinatal HIV infection: lessons learned and current challenges. Journal of the International AIDS Society, 16(1), 18593. 10.7448/IAS.16.1.18593 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Mossman SA, Luft MJ, Schroeder HK, Varney ST, Fleck DE, Barzman DH, Gilman R, DelBello MP & Strawn JR (2017). The Generalized Anxiety Disorder 7-item scale in adolescents with generalized anxiety disorder: Signal detection and validation. Annals of Clinical Psychiatry, 29(4), 227–234A. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc5765270/ [PMC free article] [PubMed] [Google Scholar]
  24. Musisi S, & Kinyanda E (2009). Emotional and behavioural disorders in HIV seropositive adolescents in urban Uganda. East African Medical Journal, 86(1), 16–24. 10.4314/eamj.v86i1.46923 [DOI] [PubMed] [Google Scholar]
  25. Namuli JD, Nalugya JS, Bangirana P, & Nakimuli-Mpungu E (2021). Prevalence and factors associated with suicidal ideation among children and adolescents attending a pediatric HIV clinic in Uganda. Frontiers in Sociology, 6. 10.3389/fsoc.2021.656739 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Olashore AA, Brooks W, Roy H Adebayo FA, & Chiliza B (2022) Psychiatric disorders and associated risk factors in a sample of adolescents in Gaborone, Botswana: a cross-sectional study. BMC Pediatrics, 22, 381. 10.1186/s12887-022-03435-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Olashore AA, Frank-Hatitchki B, & Ogunwobi O (2017). Diagnostic profiles and predictors of treatment outcome among children and adolescents attending a national psychiatric hospital in Botswana. Child and Adolescent Psychiatry and Mental Health, 11, 8. 10.1186/s13034-017-0144-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Olashore AA, Paruk S, Akanni OO, Tomita A, & Chiliza B (2021). Psychiatric disorders in adolescents living with HIV and association with antiretroviral therapy adherence in sub-Saharan Africa: A systematic review and meta-analysis. AIDS Behavior, 25(6), 1711–1728. 10.1007/s10461-020-03100-z [DOI] [PubMed] [Google Scholar]
  29. Porche D, & Giorgianni SJ Jr. (2020). The crisis in male mental health: A call to action. American Journal of Men’s Health, 14(4), 1557988320936504. 10.1177/1557988320936504 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, & Mellins CA (2019) Mental health and HIV/AIDS: the need for an integrated response. AIDS, 33(9), 1411–1420. 10.1097/QAD.0000000000002227 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Republic of Botswana. (2016a). Handbook of the Botswana 2016 integrated HIV clinical care guidelines. https://www.moh.gov.bw/Publications/Handbook_HIV_treatment_guidelines.pdf
  32. Republic of Botswana. (2016b). Second Botswana Youth Risk Behavioural and Biological Surveillance Survey Report.
  33. Republic of Botswana. (2021). Botswana AIDS Impact Survey V.
  34. Rukundo GZ, Mpango RS, Ssembajjwe W, Gadow KD, Patel V, & Kinyanda E (2020). Prevalence and risk factors for youth suicidality among perinatally infected youths living with HIV/AIDS in Uganda: the CHAKA study. Child and Adolescent Psychiatry and Mental Health, 14(1), 41. 10.1186/s13034-020-00348-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, & Dunbar GC (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33. [PubMed] [Google Scholar]
  36. Sherr L, Cluver LD, Toska E, & He E (2018). Differing psychological vulnerabilities among behaviourally and perinatally HIV infected adolescents in South Africa – implications for targeted health service provision*. AIDS Care, 30(Supp2), 92–101. 10.1080/09540121.2018.1476664 [DOI] [PubMed] [Google Scholar]
  37. Shore L, Toumbourou JW, Lewis AJ, & Kremer P (2018). Review: Longitudinal trajectories of child and adolescent depressive symptoms and their predictors – a systematic review and meta-analysis. Child and Adolescent Mental Health, 23(2), 107–120. 10.1111/camh.12220 [DOI] [PubMed] [Google Scholar]
  38. Silverstein DM (2009). Inflammation in chronic kidney disease: role in the progression of renal and cardiovascular disease. Pediatric Nephrology, 24(8), 1445–1452. 10.1007/s00467-008-1046-0 [DOI] [PubMed] [Google Scholar]
  39. Skovlund CW, Mørch LS, Kessing LV, & Lidegaard Ø (2016). Association of hormonal contraception with depression. JAMA Psychiatry, 73(11), 1154–1162. 10.1001/jamapsychiatry.2016.2387 [DOI] [PubMed] [Google Scholar]
  40. Slogrove AL, & Sohn AH (2018). The global epidemiology of adolescents living with HIV: time for more granular data to improve adolescent health outcomes. Current Opinion in HIV and AIDS, 13(3), 170–178. 10.1097/COH.0000000000000449 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Spitzer RL, Kroenke K, Williams JBW, & Löwe B (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
  42. Tommasello AC, Gillis LM, Lawler JT, & Bujak G (2006). Characteristics of homeless HIV-positive outreach responders in urban US and their success in primary care treatment. AIDS Care, 18, 911–917. 10.1080/09540120500331297 [DOI] [PubMed] [Google Scholar]
  43. Too EK, Abubakar A, Nasambu C, Koot HM, Cuijpers P, Newton CR, & Nyongesa MK (2021). Prevalence and factors associated with common mental disorders in young people living with HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society, 24(Suppl 2), e25705. 10.1002/jia2.25705 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. UNICEF. (n.d.). Mental Health. https://data.unicef.org/topic/child-health/mental-health/
  45. Ussery F, Bachanas P, Alwano MG, Lebelonyane R, Block L, Wirth K, Ussery G, Sento B, Gaolathe T, Kadima E, Abrams W, Segolodi T, Hader S, Lockman S, & Moore J (2022). HIV incidence in Botswana rural communities with high antiretroviral treatment coverage: results from the Botswana Combination Prevention Project, 2013–2017. Journal of Acquired Immune Deficiency Syndrome, 91(1), 9–16. 10.1097/QAI.0000000000003017 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Woollett N, Cluver L, Bandeira M, & Brahmbhatt H (2017). Identifying risks for mental health problems in HIV positive adolescents accessing HIV treatment in Johannesburg. Journal of Child and Adolescent Mental Health, 29(1), 11–26. 10.2989/17280583.2017.1283320 [DOI] [PubMed] [Google Scholar]
  47. World Health Organization. (2019). The Global Health Observatory: age-standardized suicide rates. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/age-standardized-suicide-rates-(per-100-000-population)
  48. World Health Organization. (2021). Mental health of adolescents. WHO. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health#:~:text=Globally%2C%20one%20in%20seven%2010-19-year-olds%20experiences%20a%20mental,fourth%20leading%20cause%20of%20death%20among%2015-19%20year-olds.?msclkid=b797f270b1ae11ecaffaf281f06bdcb2 [Google Scholar]
  49. World Health Organization. (n.d.). The Global Health Observatory: Adolescent Mortality Rate (per 100 000 population). https://www.who.int/data/gho/data/indicators/indicator-details/GHO/adolescent-mortality-rate-(per-100-000-population)
  50. Xu X, Mishra GD, & Jones M (2019). Trajectories of mental health symptoms for women in their 20s predict the onset of chronic physical conditions in their 30s: Two decades of follow-up of young Australian women. Journal of Affective Disorders, 246, 394–400. 10.1016/j.jad.2018.12.106 [DOI] [PubMed] [Google Scholar]
  51. Yang E, Mphele SBM, Moshashane N, Bula B, Chapman J, Okatch H, Pettitt E, Tshume O, Marukutira T, Anabwani G, & Lowenthal E (2018). Distinctive barriers to antiretroviral therapy adherence among non-adherent adolescents living with HIV in Botswana. AIDS Care, 30, 224–231. 10.1080/09540121.2017.1344767 [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Yemeke TT, Sikkema KJ, Watt MH, Ciya N, Robertson C, & Joska JA (2020). Screening for traumatic experiences and mental health distress among women in HIV care in Cape Town, South Africa. Journal of Interpersonal Violence, 35(21–22), 4842–4862. 10.1177/0886260517718186 [DOI] [PMC free article] [PubMed] [Google Scholar]

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