Abstract
We investigated psychological distress and symptoms of depression and anxiety among 485 South Africans seeking HIV testing. The mean scores of the sample were 45.78 (SD=16.81) on the Hopkins Symptom Checklist; 15.8 (SD=12.4) on the Beck Depression Inventory; and 12.44 (SD=13.00) on the Beck Anxiety Inventory, which fell in the elevated, mild, and low ranges on these instruments, respectively. For more than a third of participants, symptoms of depression and clinically significant distress were at least moderate and in some cases severe, indicating that they may have benefitted from psychological help. We make the case that symptoms of depression and distress are common among persons seeking HIV testing and are therefore not a consequence of an HIV positive test result.
Keywords: Depression, distress, anxiety, test-seeking
It has been assumed that receipt of an HIV positive result may cause a person to become depressed, traumatised, or in some way psychologically disordered (e.g. Freeman, 2004). Yet, it is largely unknown whether psychological distress precedes HIV testing or whether receipt of an HIV positive test precipitates distress.
Persons living with HIV in South Africa often have high rates of depressive symptoms e.g. 34.9% (Olley, Gxamza, Seedat, Theron, Taljaard, Reid, Reuter, & Stein, 2003); 14% (Myer, Smit, Roux, Parker, Stein, & Seedat, 2008); and 11.1% (Freeman, Nkomo, Kafaar, & Kelly, 2007) and are comparably higher than that of the general South African population, which was found to be 9.8% (Herman, Stein, Seedat, Heeringa, Moomal, & Williams, 2009). In this study we report on symptoms of depression, anxiety and distress among persons seeking HIV testing, i.e. prior to their receiving an HIV test result.
METHOD
Participants
Participants were recruited by means of convenience sampling at five HIV testing sites in South Africa.
Procedures
When HIV test-seekers registered at the testing site, they were handed a flyer about the study and invited to meet with a researcher who invited them to participate. Those who agreed completed an informed consent form and participated in an interview. Eligibility criteria included not having symptoms of a psychotic disorder and being able to understand English.
Data collection
A cadre of trained data collectors administered the measures using an electronic tablet. The study was approved by the Stellenbosch University Health Ethics Committee. Participants who had clinically significant distress or a mental disorder were referred to a local mental health centre.
Measures
Psychological distress
We used the 25-item version of the Hopkins Symptom Checklist (HSCL-25; Hough et al., 1982) to assess global psychological functioning over the past month. The HSCL has been used in several studies among South African samples (Kagee, 2005; Kagee, 2008; Nel & Kagee, 2011; Kagee & Martin, 2010).
Symptoms of depression
The 21 item Beck Depression Inventory (BDI) (Beck, Steer, Garbin, 1988) was used to measure symptoms of depression. It has been used in a variety of studies worldwide, including South African (Martin & Kagee, 2010; Kagee, 2008).
Symptoms of anxiety
The 21 item Beck Anxiety Inventory (BAI) was used to measure symptoms of anxiety during the week prior to participating in the study. The scale has demonstrated high content, concurrent, construct, discriminant, and factorial validity (Beck & Steer, 1993; Steel and Edwards, 2008).
Analysis
SPSS version 22 was used to calculate descriptive statistics and conduct t-tests.
RESULTS
Description of the sample
525 test-seekers were approached, of whom 40 (7.6%) declined, yielding 485 participants (49.1% males; 50.9% females; mean age 36 years). As shown in Table 1, most participants (72.0%) classified themselves as “Coloured” (an apartheid racial category indicating mixed heritage), followed by 26.8% African and 0.8% White. Most participants (68.5%) indicated Afrikaans as their first language, and 6.0% and 20.0% stated that English and isiXhosa were their first languages, respectively. Almost all participants were conversant in English. Nearly half the sample were unemployed and had a family income of less than R10 000 ($750) per annum.
Table 1.
Demographic Characteristics of the Sample
| Number of respondents (n = 485) |
% of total sample |
|
|---|---|---|
| Gender | ||
| Male | 238 | 49.1 |
| Female | 247 | 50.9 |
|
| ||
| Race | ||
| African | 130 | 26.8 |
| “Coloured” | 349 | 72.0 |
| White | 4 | 0.8 |
| Other | 2 | 0.4 |
| First language | ||
| Afrikaans | 332 | 68.5 |
| English | 29 | 6.0 |
| Xhosa | 97 | 20.0 |
| Other | 27 | 5.5 |
| Current work situation | ||
| Employed fulltime | 95 | 19.6 |
| Employed part-time | 101 | 20.8 |
| Unemployed | 228 | 47.0 |
| Homemaker | 11 | 2.3 |
| Student | 28 | 5.8 |
| Disabled | 6 | 1.2 |
| Retired | 16 | 3.3 |
| Annual family income | ||
| Less than *ZAR10 000 | 194 | 40.0 |
| ZAR 10 001 – ZAR40 000 | 199 | 41.0 |
| ZAR 40 001 – ZAR 80 000 | 56 | 11.5 |
| ZAR 80 001 – ZAR 110 000 | 20 | 4.1 |
| ZAR 110 001 – ZAR 170 000 | 8 | 1.6 |
| ZAR 170 001 – ZAR 240 000 | 5 | 1.0 |
| ZAR 240 000 and above | 3 | 0.6 |
|
| ||
| *15ZAR = 1USD | ||
|
| ||
| Age (years) | ||
| Mean | 36.09 | |
| Median | 34.00 | |
| Range | 53 | |
| Minimum | 18 | |
| Maximum | 71 | |
Psychological distress
The internal consistency coefficients for the HSCL, BDI and BAI as measured by Cronbach’s alpha were excellent: 0.95, 0.91, and 0.94, respectively. Table 2 shows the sample means for these measures. As can be seen in Table 3, the mean score on the HSCL was 45.58, which was in the clinically significant range and was significantly higher (p=0.02) than the cut-point for clinically significant distress of 44. The mean score on the BDI was in the range for mild depression and the mean score on the BAI was in the range for low anxiety. As can be seen in Tables 4, 5 and 6, on the HSCL 43.9% of the sample scored in the clinically significant range; on the BDI 38.4% scored in the moderate and severe ranges; and on the BAI 21.2% scored in the moderate to severe range.
Table 2.
Means on the HSCL, BDI and BAI
| Instrument | N | Mean | SD |
|---|---|---|---|
| HSCL Anxiety | 493 | 17.3 | 6.29 |
| HSCL Depression | 493 | 28.46 | 11.23 |
| HSCL Total | 485 | 45.78 | 16.8 |
| BDI | 454 | 15.8 | 12.4 |
| BAI | 485 | 12.44 | 13.00 |
Table 3.
Results of T-test for difference between the sample mean and clinical cut-point of 44
| Mean | SD | T | Df | Sig (2- tailed) |
Mean diff. |
95% CI | |
|---|---|---|---|---|---|---|---|
| HSCL-Tot | 45.78 | 16.81 | 2.33 | 484 | 0.02 | 1.78 | 0.28–3.28 |
Table 4.
Percentage of sample scoring above clinical cut-point of 44 on HSCL
| N | % | |
|---|---|---|
| 44 ≤ | 272 | 55.2 |
| > 44 | 213 | 43.9 |
Table 5.
Percentages of the sample in each BDI category
| N | % | |
|---|---|---|
| Normal (5–9) | 184 | 37.3 |
| Mild to moderate (10–18) | 135 | 27.4 |
| Moderate to severe (19–29) | 97 | 19.7 |
| Severe (30–63) | 77 | 15.6 |
Table 6.
Percentages of the sample in each BAI category
| N | % | |
|---|---|---|
| Low anxiety (0–21) | 382 | 78.8 |
| Moderate anxiety (22–35) | 65 | 13.4 |
| Severe anxiety (36–63) | 38 | 7.8 |
In Table 7, we summed the percentage of the sample who endorsed the HSCL items “quite a bit” and “extremely”. Those most commonly endorsed were “worrying too much about things” (43.8%), followed by “headaches” (34.8); “blaming yourself for things” (32.3%); “feeling low in energy” (28.8%); “feeling hopeless” (28.6%) and “feeling lonely” (28.6%).
Table 7.
Percentages of the sample endorsing items of the HSCL
| Item no | Item Name | Not at all | A little | Quite a bit | Extremely | Quite a bit + extremely |
|---|---|---|---|---|---|---|
| 1 | Suddenly scared for no reason | 59.4 | 25.8 | 11.0 | 3.9 | 14.9 |
| 2 | Feeling fearful | 56.6 | 26.8 | 12.2 | 4.5 | 16.7 |
| 3 | Faintness, dizziness | 50.1 | 29.0 | 13.4 | 7.5 | 20.9 |
| 4 | Nervousness, shakiness | 50.7 | 27.4 | 16.6 | 5.3 | 21.9 |
| 5 | Heart pounding | 52.5 | 28.6 | 12.8 | 6.1 | 18.9 |
| 6 | Trembling | 72.0 | 18.3 | 6.9 | 2.8 | 9.7 |
| 7 | Feeling tense or keyed up | 46.5 | 30.6 | 14.8 | 8.1 | 22.9 |
| 8 | Headaches | 30.2 | 34.9 | 17.8 | 17.0 | 34.8 |
| 9 | Spells of terror or panic | 66.9 | 20.7 | 9.7 | 2.6 | 12.3 |
| 10 | Feeling restless, can’t sit down | 49.1 | 25.4 | 15.4 | 10.1 | 25.5 |
| 11 | Feeling low in energy | 37.9 | 33.3 | 17.8 | 11.0 | 28.8 |
| 12 | Blaming yourself for things | 40.0 | 27.8 | 18.1 | 14.2 | 32.3 |
| 13 | Crying easily | 45.6 | 27.0 | 11.8 | 15.6 | 27.4 |
| 14 | Loss of sexual interest | 51.1 | 22.3 | 14.4 | 12.2 | 26.6 |
| 15 | Poor appetite | 53.5 | 24.9 | 12.6 | 8.9 | 21.5 |
| 16 | Difficulty falling asleep | 46.2 | 25.8 | 13.0 | 15.0 | 28.0 |
| 17 | Feeling hopeless | 46.0 | 25.4 | 12.8 | 15.8 | 28.6 |
| 18 | Feeling blue | 55.4 | 25.2 | 12.8 | 6.7 | 19.5 |
| 19 | Feeling lonely | 47.1 | 24.3 | 13.4 | 15.2 | 28.6 |
| 20 | Feeling trapped or caught | 59.2 | 20.3 | 12.2 | 8.3 | 20.5 |
| 21 | Worrying too much about things | 25.6 | 30.6 | 18.9 | 24.9 | 43.8 |
| 22 | Feeling no interest in things | 49.7 | 25.2 | 15.0 | 10.1 | 25.1 |
| 23 | Thoughts of ending your life | 73.2 | 12.8 | 7.3 | 6.7 | 14.0 |
| 24 | Feeling everything is an effort | 46.2 | 30.6 | 13.6 | 9.5 | 23.1 |
| 25 | Feelings of worthlessness | 54.8 | 20.9 | 13.0 | 11.4 | 24.4 |
Symptoms of depression
Table 2 displays the mean score of the sample on the BDI of 15.8 and the associated standard deviation of 12.4, which fell in the mild to moderate range. As can be seen in Table 5, more than a third of the sample scored in the moderate and severe ranges and nearly one fifth (17%) scored in the severe range, indicating that a substantial proportion of the sample experienced clinically significant symptoms of depression.
As can be seen in Table 8, more than 30% of participants endorsed all items on the BDI, with the exception of the suicidality item. Further, more than 50% of the sample endorsed 8 items in the scoreable direction, namely, Pessimism, Loss of satisfaction, Self-criticalness, Irritability, Work inhibition, Sleep disturbance, Somatic preoccupation, and Tiredness or fatigue. Nearly, 80% of the sample reported minimal anxiety and about one fifth reported moderate or severe anxiety.
Table 8.
Percentage of participants who endorsed scores on the BDI in the scoreable direction
| Item | % endorsed in the scoreable direction |
|---|---|
| Sadness; low mood | 45.6 |
| Pessimism | 51.0 |
| Sense of failure | 46.5 |
| Loss of satisfaction | 57.1 |
| Feelings of guilt | 46.6 |
| Sense of being punished | 48.7 |
| Self-hate | 43.0 |
| Self-criticalness | 51.5 |
| Suicidal thoughts or wishes | 23.9 |
| Crying spells | 39.7 |
| Irritability | 50.5 |
| Loss of interest | 44.6 |
| Indecisiveness | 42.6 |
| Body image | 34.6 |
| Work inhibition | 54.1 |
| Sleep disturbance | 50.4 |
| Somatic preoccupation | 52.0 |
| Loss of libido | 48.4 |
| Tiredness or fatigue | 52.5 |
| Loss of appetite | 49.5 |
| Weight loss | 42.7 |
DISCUSSION
On average, participants in the study reported elevated psychological distress. The HSCL mean score of 45.58 was significantly higher than the commonly used cut-point of 44 and comparable with other South African samples, for example, South African former political detainees (56.18) (Kagee, 2005), patients living with hypertension (45.39); diabetes (41.36); and HIV (47.24) (Kagee, 2010). Almost half our sample scored in the clinically significant range on the HSCL. The major indicators of distress were worry, self-blame, low energy and hopelessness. Less than half the sample reported being employed and thus the demands on cognitive capacity brought on by unemployment may have led to excessive worry, self-blame and a sense of hopelessness. It is possible that a residual level of psychological distress may be present in many poor South African communities that is independent of their seeking HIV testing.
On the BDI, the mean score of the sample fell in the range for mild depression, although 38.4% scored in the moderate to severe range. More than a third of participants had clinically significant symptoms of depression and may have benefitted from psychological help.
Several items were endorsed in the scoreable direction by over 50% of the sample. These items – Pessimism, Loss of satisfaction, Self-criticalness, Irritability, Work inhibition, Sleep disturbance, Somatic preoccupation, and Fatigue – have significant implications for the quality of life of study participants. Our data do not permit us to speculate whether it is HIV test-seeking – and presumably a sense of HIV risk – that accounted for our results, as we did not compare the sample to members of the general public who were not seeking testing. This is a potential area for further study.
On the BAI, the mean score of the sample fell in the low range. More than one fifth of participants scored in the moderate to severe range, indicating that anxiety was indeed a concern for these individuals. However, it was not a salient feature of the psychological condition for most participants, which is consistent with our findings on the anxiety subscale of the HSCL.
Rather than being precipitated by an HIV test result, we found that distress and symptoms of depression and anxiety are part of the psychological presentation of individuals seeking an HIV test. Many individuals may have symptoms of common mental disorders even prior to HIV testing. Thus it is necessary to explore ways to integrate psychological services within the HIV testing context so that these symptoms may be resolved in a timely manner. At the very least, staff at testing sites should be alerted to the possibility that test-seekers may be distressed. A referral trajectory should be identified that those needing psychological support may access.
Individuals who test positive for HIV and who are also depressed or otherwise distressed are less likely to enrol in antiretroviral therapy and those who do are less likely to be adherent to their medical regimens than persons who are non-distressed (Nel & Kagee, 2011; 2013). If psychological screening is implemented in the context of routine HIV testing, then individuals who have elevated distress may be followed up to determine the nature and severity of their symptoms and then referred for psychological treatment. The existence of such referral trajectories require adequate funding in the health system which, in the context of competing public health needs, may be difficult. Nonetheless, unmet mental health needs of HIV test-seekers require the attention of health policy makers.
Almost all participants who were approached to participate did so, thus minimising the likelihood of sampling bias. As the sample was recruited in the Western Cape in South Africa, generalising our results to other provinces is limited. Medical services, particularly primary health care, in South Africa remains largely biomedical and focuses on symptoms of physical illness. This study highlights the need for integrated person-centred psychological care at primary health care level in South Africa.
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