Mental health of HIV-infected patients: A severe, but Overlooked Problem

Abstract

HIV-infected patients are known to have severe psychosocial problems; however, clinicians tend to overlook these psychosocial issues. Song et al. identified depression and anxiety as the most common mental illnesses among HIV-infected patients. Psychosocial issues are important factors and are associated with poor adherence, which leads to treatment failure and resistance. Clinicians who tend to HIV patients should be attentive to the patients' psychosocial problems and regularly conduct screening for depressive disorders. Mental health must be addressed to improve the quality of life of patients with HIV/AIDS.

The introduction of antiretroviral treatment (ART) into clinical practice has led to dramatic reductions in morbidity and mortality associated with HIV infection [1]. With the success of ART, HIV infection is no longer an acutely devastating illness, but a controllable disease. However, many non-AIDS complications that limit the quality of life of HIV-infected persons have emerged. Mental illnesses such as HIV-associated neurocognitive disorder (HAND) and depression are important complications limiting the quality of life of HIV/AIDS patients. HIV enters the central nervous system (CNS) early after infection. Although HIV does not directly infect neurons, it is frequently associated with structural and functional brain abnormalities. Significant brain involvement occurs in individuals with an AIDS-defining opportunistic condition (approximately 50%), but neurocognitive changes also occur in about one-third of individuals in the early, medically asymptomatic phases of the disease. Depression is the most common mental illness among HIV-infected persons. There is a higher prevalence of depression in HIV infected persons (20-40% versus 7% in general population) due to stigma, sexual dysfunction, side effects of ART, and co-morbidities [2].

Song et al. [8] investigated the prevalence and risk factors for depression among HIV-infected Koreans. They found that the prevalence of depression was more than 20% in this population. Co-morbidities and unemployment were risk factors for depression among HIV-infected Koreans. In addition, patients with depression tended to miss their clinical appointments.

Few studies have examined the psychosocial aspects of HIV-infected Koreans. However, Lee et al. did compare the psychosocial variables among 27 HIV-infected Koreans, 29 patients who received hematopoietic stem cell transplantation, 30 healthy controls [3]. In their study, patients were evaluated using hospital anxiety and depression scales. Lee et al. found that compared with healthy controls, HIV-infected patients had higher scores of depression and anxiety as well as higher perceived stress. HIV patients also had a lower family support than both hematopoietic stem cell transplantation patients and healthy controls.

In another study, Lee et al. evaluated the psychosocial factors associated with biological markers in 50 HIV-infected Koreans [4]. They found a significant correlation between psychosocial factors and CD4+ cell counts. In the Stress Response Inventory, subscales for tension, aggression, depression, and frustration showed that these factors had a negative correlation with the CD4+ cell count. In addition, distancing and self-control in the coping scale also had a negative correlation with CD4+ cell count. They concluded that the use of a passive coping strategy, like distancing, might be an important factor influencing the progression of HIV infection. Lee et al. indicated that psychosocial interventions are needed for HIV-infected patients.

Studies have consistently shown that many HIV-infected Koreans have severe psychosocial problems such as depression and anxiety. These findings are consistent with those from studies in other countries. A meta-analysis showed that the frequency of major depressive disorder was almost 2 times higher in HIV-positive subjects than in HIV-negative subjects [2].

Although adherence to ART is associated with HIV viral suppression, reduced rates of resistance, increased survival, and improved quality of life, poor adherence is very common in HIV-infected patients receiving lifelong ART [5]. Psychosocial issues such as depression, homelessness, low social support, stressful life events, or psychosis are factors associated with non-adherence [6]. Song et al. [8] found that depressed Korean patients were more likely to miss clinical appointments. In addition, they found that only small proportion of Korean patients with depressive disorder are referred to neuropsychologists. Therefore, prior to initiating ART, clinicians should conduct a psychiatric assessment of the patient and consider ways to improve his/her mental health.

The European AIDS Clinical Society (EACS) guidelines recommend that clinicians perform screening for depression every 1-2 years. Depression screening is assessed using 2 main questions: (1) "Have you often felt depressed, sad or without hope in the last few months?" and (2) "Have you lost interest in activities that you usually enjoy?" [7]. If the patient has a depressive disorder, a prescription for antidepressants such as selective serotonin-reuptake inhibitors (SSRIs), dual-action reuptake inhibitors, or mixed action newer agents should be given while considering the accompanying drug interactions between antidepressants and antiretroviral drugs. Patients with severe depression should be referred to a Psychiatry specialist.

People with HIV/AIDS in Korea face tremendous psychosocial challenges, including HIV-related stigma, lack of social support, and mental health issues. These issues pose a serious threat to their human right to health and quality of life. Society, clinicians, family, as well as the patients themselves should make every effort necessary to help patients overcome these challenges.