Psychiatric morbidity in asymptomatic human immunodeficiency virus patients

Abstract

Background:

Psychiatric morbidity in human immunodeficiency virus (HIV) patients is being studied all over the world. There is paucity of Indian literature particularly in asymptomatic HIV individuals.

Aim:

The aim of the following study is to establish the prevalence and the determinants of psychiatric morbidity in asymptomatic HIV patients.

Materials and Methods:

A cross-sectional study was undertaken to assess psychiatric morbidity as per ICD-10 dacryocystorhinostomy criteria in 100 consecutive asymptomatic seropositive HIV patients and an equal number of age, sex, education, economic and marital status matched HIV seronegative control. All subjects were assessed with the general health questionnaire (GHQ), mini mental status examination, hospital anxiety and depression scale (HADS) and sensation seeking scale (SSS) and the scores were analyzed statistically.

Results:

Asymptomatic HIV positive patients had significantly higher GHQ caseness and depression but not anxiety on HADS as compared to HIV seronegative controls. On SSS asymptomatic HIV seropositive subjects showed significant higher scores in thrill and adventure seeking, experience seeking and boredom susceptibility as compared to controls. HIV seropositive patients had significantly higher incidence of total psychiatric morbidity. Among the individual disorders, alcohol dependence syndrome, sexual dysfunction and adjustment disorder were significantly increased compared with HIV seronegative controls.

Conclusion:

Psychiatric morbidity is higher in asymptomatic HIV patients when compared to HIV seronegative controls. Among the individual disorders, alcohol dependence syndrome, sexual dysfunction and adjustment disorder were significantly increased compared with HIV seronegative controls. High sensation seeking and substance abuse found in HIV seropositive patients may play a vital role in engaging in high-risk behavior resulting in this dreaded illness.

The recognition of the clinical manifestations of psychiatric disorders in human immunodeficiency virus (HIV) patients is currently a major challenge. Despite the high prevalence, psychiatric disorders in HIV patients are often under diagnosed and undertreated.[1] Late recognition of mental disorders in HIV patients is related with diminished coping capacity at diagnosis,[2,3] poorer anti-retroviral adherence,[4] impairment in quality of life,[5] greater social burden[6] overall increase in health care costs[7] and higher mortality.[8]

Psychiatric morbidity in HIV Patients is being studied all over the world. Various studies have shown that neuropsychiatric complications occur in at least 5-59% of HIV infected patients and may be the first sign of disease in about 10% of the patients.[1,9,10,11,12] There is a paucity of Indian literature particularly in asymptomatic HIV individuals. Hence, the present study has been undertaken to find out the prevalence of psychiatric morbidity in asymptomatic HIV patients and to identify various determinants that affects the psychiatric morbidity in asymptomatic HIV patients.

MATERIALS AND METHODS

The study was undertaken at a large urban multispecialty tertiary-care teaching hospital. The study had the approval of the institutional research ethics committee. A cross-sectional design was employed and written informed consent was obtained from all the subjects taken up for the study.

Sample

All asymptomatic HIV patients who were admitted to the hospital at the time of evaluation were included in the study. HIV seropositivity was confirmed by two different enzyme-linked immunosorbent assay methods. Staging of HIV seropositive cases was carried out as per centers for disease control (CDC) classification. The eligible cases were assigned to either Stage II or Stage III of CDC. Patients in Stage IV were not eligible for the study. Although interviewers knew of the seropositive status, they were not aware of the stage of HIV disease prior to the psychological assessment. An equal number of normal persons were selected as controls. The controls were comparable with the cases regarding their age, education, sex, monthly income and occupation.

Inclusion criteria for patients

• Confirmed HIV seropositivity

• Physically asymptomatic in Stage II or III

• Age between 15 and 50 years.

Inclusion criteria for controls

• Confirmed HIV seronegativity

• Age between 15 and 50 years

• Physically asymptomatic at the time of evaluation.

Exclusion criteria for patients and controls

• Past history or presence of central nervous system disorders

• History of head injury with loss of consciousness

• Past history of psychiatric illness

• Patients who qualify acquired immune deficiency syndrome (AIDS) defining criteria.

Procedure

After enrolment into the study, a semi-structured proforma was used to record demographic details and assess risk factors for HIV infection. Physical examination, mental status evaluation and relevant laboratory investigations (hemogram, urine routine examination, liver function test, Hepatitis B antigen, venereal disease research laboratory and others if required) were carried out to exclude cases and controls not eligible for the study. Psychiatric diagnoses were made by the resident and confirmed by a consultant psychiatrist. Psychiatric diagnoses were made as per the ICD-10 classification of mental and behavioral disorders diagnostic criteria for research.[13]

All subjects underwent the following psychiatric rating scales:

• General health questionnaire (GHQ)[14]

• Mini mental state examination (MMSE)[15]

• Hospital anxiety and depression scale (HADS)[16]

• Sensation seeking scale (Indian adaptation).[17]

Scoring was done as per the test booklet of each scale. The results were tabulated and subjected to statistical analysis. The socio-demographic characteristics of the group were compared by the Chi-square test. For comparing the scores on psychiatric rating scales the Mann-Whitney U-test was used.

RESULTS

A total of 200 subjects were included in the study of which 100 were cases (HIV seropositive) and 100 were controls (HIV seronegative). Demographic and clinical characteristics of the subjects are given in Table 1. All the subjects were males. This selection bias was due to the fact that the hospital catered to predominantly male population. Of the HIV seropositive patients 75 were married compared with 73 of the seronegative subjects. The difference was not statistically significant (χ² = 0.03; df = 1; P = 0.872). Though 75% of the HIV seropositive subjects were married however, only 5-6% was staying with their spouses due to the nature of their employment. They were meeting with their spouses during their annual/casual leave. Duration of HIV seropositivity was 0-6 months in 55 patients; nine patients each were seropostive for 6-12 months, 12-18 months and 18-24 months; seven patients each were seropositive for 24-30 and 30-36 months; while two patients each were positive for 36-42 months and >42 months. The risk factors for HIV infection included heterosexual promiscuity (n = 85), multiple injections/tattooing (n = 3), transfusion of unscreened blood (n = 2), health worker handling infected blood (n = 1) while in nine patients no risk factor could be identified. Neither cases nor controls showed any cognitive dysfunction on MMSE (Score < 24). The observed GHQ-12 “caseness” (a cut-off score of 2) for HIV and control groups was 49 and 9 respectively [Table 2]. The difference was statistically significant (χ² = 38.85; df = 1; P < 0.0001). All the patients who ultimately were given a psychiatric diagnosis had abnormal scores on GHQ. Thus in the present study, GHQ-12 had a sensitivity of 100% and specificity of 92% for detecting psychiatric morbidity in asymptomatic HIV patients. Results of the psychiatric rating scales are given in Tables 2 and 3. Results of psychiatric evaluation are given in Table 4.

Table 1.

Demographic characteristics of HIV positive and negative subjects

Table 2.

Results of GHQ and HADS

Table 3.

Results of sensation seeking scale

Table 4.

Psychiatric disorders in asymptomatic HIV subject

DISCUSSION

The fundamental premise of modern psychiatry is that emotional life and behaviors have biological underpinnings that develop and are shaped within a broader social context. Perhaps that interplay is nowhere more evident than in the psychobiology of HIV infection. The changing face of the HIV pandemic from one of accelerating deterioration to a more chronic course suggests that the role of clinical psychiatry must expand to encompass new populations and to adapt to changing neuromedical aspects of illness.[18] The transition model proposes that adverse psychological phenomenon (e.g., adjustment disorders, mood disorders and anxiety disorders) may be anticipated at key points such as discovery of seroconversion, initiation of anti-retroviral treatment, onset of physical symptoms, advance in HIV related illness stage and HIV related bereavement and that they reflect a breakdown in coping capacities in the face of HIV.[19] Various studies have suggested that four factors are important in explaining the increased psychiatric morbidity in HIV patients. They are pre-existing psychiatric morbidity,[20] neurotoxic property of HIV itself,[21] terminal nature of diagnosis[21] and social stigmatization.[22]

In the present study, the psychiatric morbidity was assessed in asymptomatic HIV patients (Stage II and III of CDC classification) as psychiatric manifestations in advanced stages, i.e., AIDS may be due to opportunistic or central nervous system infections. These guidelines were not followed by many of the studies, which resulted in erroneous observations.[23,24,25] Some studies have kept sexually transmitted diseases patients as controls in view of similar social stigmatization,[26,27] others high risk HIV seronegative persons (homosexuals and IV drug users)[28,29] and still others rheumatoid arthritis.[11] Control subjects in this study were the normal healthy persons who had the same atmosphere and background as of the cases. Normal persons were kept as controls to find out the exact phenomenology of asymptomatic HIV patients and their difference in sensation seeking. Most of the studies have assessed one or at the most two of the variables and that too on symptomatic population. This study has adequately large samples and studied all the relevant psychiatric variables. The age range of the patients in present study Table 1 was on par with other studies.[20,24,26] Risk factors for HIV infection were similar to previous Indian studies.[11,24,30,31] On the other hand, the western studies had higher number of homosexual transmission and intravenous drug abuse.[25,28]

The observed GHQ-12 “caseness” (a cut-off score of 2) for HIV and control groups [Table 2] was within the ranges reported in literature.[11,24,32] In the present study, GHQ-12 had a sensitivity of 100% and specificity of 92% indicating that it is a good screening test for psychiatric morbidity in asymptomatic HIV patients.

The finding of absence of cognitive dysfunction in patients in the present study is in agreement with an earlier study.[11] Contrary findings of 10.5% cognitive impairment in an earlier Indian study[24] was probably due to inclusion of symptomatic (Stage IV CDC) HIV patients in that study. We can conclude from the above observations that asymptomatic HIV patients do not result in any gross cognitive dysfunction. Singh et al.[31] studied cognitive function in asymptomatic HIV seropositive individuals by using Luria-Nebraska neuropsychological battery and reported slower fine motor speed and slower speed of information processing and no difference in any other cognitive domain. This indicates that the utility of MMSE as a good screening test for assessment of cognitive dysfunction in asymptomatic HIV patients needs further evaluation.

The observation of higher prevalence of anxiety on HADS [Table 2] in HIV seropositive individuals was similar to earlier studies.[1,33,34] The very knowledge of harboring a potentially fatal infection of uncertain prognosis, with bleak treatment prospects and possible suffering and social isolation can be sufficiently stressful to induce anxiety. Symptoms of anxiety may increase fatigue and physical functional limitations.[35] The finding of significantly higher depression on HADS [Table 2] in HIV seropositive subjects is similar to earlier studies.[1,36,37] Among HIV patients, clinical depression has been reported frequently,[38] but estimates concerning its prevalence has varied considerably (30-61%), but always greater than in the general population (4-40%).[1] These findings are confirmed in the present study. It is not yet determined whether HIV itself increases the likelihood of major depressive disorder beyond the expected increases found in other chronic diseases. HIV infection can be associated with anergic-apathetic-fatigue states, presumably mediated by release of somnogenic lymphokines.[25] Various studies have brought out factors, which led to higher rates of depression in HIV patients: Decline of immunocompetence, adverse life events, pre-existing mood disorder, noting the onset of constitutional symptoms and initiating retroviral therapy.[39,40] It is imperative that depression in HIV positive patients must be identified and treated because depression has been associated with a lower likelihood of receiving anti-retrovirals and poor adherence, which leads to a worse outcome in HIV infected persons and increased mortality.[1]

Sensation seeking is a personality factor that could have an important role in HIV risk behavior. Sensation seeking focuses on the need for new and varied experiences through uninhibited behavior, these include dangerous activities, a non-conventional life-style and a rejection of monotony.[41] Sensation seeking trait was assessed under the four different characteristics in the present study Table 3. Thrill and adventure seeking, experience seeking and boredom susceptibility revealed statistically significant higher scores in asymptomatic HIV patients compared with HIV seronegative controls. However, disinhibition scores did not reveal any statistically significant difference between two groups. These findings were similar to findings of earlier studies.[42,43,44,45] High sensation seeking trait may play a vital role in engaging in high-risk behavior resulting in this dreaded illness. More complementary studies are needed to identify different aspects of sensation seeking and methods of effective intervention for prevention of HIV.

In the present study, HIV seropositive patients had significantly higher incidence of psychiatric disorders including alcohol dependence, adjustment disorder and sexual dysfunction [Table 4]. Five out of the nine HIV seropositive patients with sexual dysfunction had no concurrent Axis 1 diagnosis. Impaired sexual functioning contributes to diminished quality of life for seropositive patients, many of whom report this as a significant loss in their lives. The high prevalence of sexual dysfunction in these patients is an important finding given the low base rates of this disorder in male population under age 44. All the men experienced sexual dysfunction after notification of HIV positive status. This finding is consistent with earlier studies in service personnel.[24,46] Overall, there was moderate agreement between interviewer's diagnosis of depression and patient's self-report of depressive symptoms on an assessment scale in the present study, consistent with the findings of an earlier study.[47]

The significantly higher prevalence of alcohol dependence syndrome confirmed the findings by Rosenberg et al.[23] who reported alcohol as the strongest predictor of HIV drug risk behaviors, stronger than drug use generally. Most patients with substance abuse disorders had developed these disorders before acquiring HIV which is in agreement with earlier report.[48] Substance abusers are prone to have high risk sexual behaviors, as there is a higher rate of non-inhibition, impaired judgment and impulsivity.[1,49] For these same reasons, they tend to be less compliant with anti-retroviral regimens.[50] Furthermore, alcohol use can accelerate HIV disease progression.[51] Mounting evidence suggests that these patients have accelerated and more severe neurocognitive dysfunction compared with non-substance-abusing HIV-infected populations.[52,53]

CONCLUSIONS

Psychiatric morbidity is significantly higher in asymptomatic HIV patients as compared to HIV seronegative controls. Among the individual disorders, alcohol dependence syndrome, sexual dysfunction and adjustment disorder were significantly increased compared with HIV seronegative controls. High sensation seeking and substance abuse found in HIV seropositive patients may play a vital role in engaging in high-risk behavior resulting in this dreaded illness.