Suicidality in AIDS long-term survivors: what is the evidence?

Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation

BACKGROUND

Compared to active ideation, passive ideation remains relatively understudied and its clinical importance poorly defined. The weight that should be accorded passive ideation in clinical risk assessment is therefore unclear.

METHODS

We conducted a systematic review and meta-analysis of the prevalence of passive ideation, its psychiatric comorbidity, associated sociodemographic characteristics, as well as psychological and environmental correlates. For reference, pooled effects were also calculated for direct comparisons of passive and active ideation with respect to potential correlates. Relevant articles published since inception to 9 September 2019 were identified through a systematic search of MEDLINE and PsycINFO.

RESULTS

A total of 86 studies were included in this review. The prevalence of passive ideation was high across sample types, ranging from 5.8% for 1-year prevalence to 10.6% for lifetime prevalence in the general population. Passive ideation was strongly associated with sexual minority status, psychiatric comorbidity, psychological characteristics implicated in risk, and suicide attempts. Preliminary evidence exists for a large association with suicide deaths. The effect sizes for individual correlates of passive and active ideation were largely equivalent and mostly non-significant in head-to-head comparisons.

CONCLUSIONS

Passive ideation is a prevalent clinical phenomenon associated with significant psychiatric comorbidity. Current evidence also suggests notable similarities exist between passive and active ideation in terms of psychiatric comorbidity and psychological and other characteristics traditionally associated with risk.

Trauma and Growth: Impact of AIDS Activism

Introduction

Our goal was to assess the long-term impact of AIDS activism of ACT UP/New York on the current adjustment of those who were members during its peak years (1987-1992), including assessment of trauma sequelae as well as posttraumatic growth.

Methods

A 90-minute semistructured interview and 6 validated self-report scales were administered. We relied on purposive and snowball sampling to recruit potential participants. Areas covered include demographics, ACT UP participation, and psychiatric problems. Self-report scales provided approximate diagnoses of PTSD and depression, as well as coping, optimism, and related concepts.

Results

Participants included 102 men (40% HIV-positive) and 23 women. Seventeen percent reported current symptoms suggesting PTSD, slightly above the range in general population studies. Symptoms consistent with depression were reported by 8% overall, with higher rates for HIV+ men. Enhanced sense of self, belief in change, and empowerment were reported by 93% of respondents, independent of concurrent PTSD or depression.

Conclusions

Twenty-eight years later, ACT UP study participants recall their activist days during the AIDS epidemic as the peak experience of their lives. While some continue to have symptoms of stress and depression, most found that their activism has enriched their subsequent lives.

'Now and Again It Really Hits Me'

Quantitative and qualitative data were gathered from a sample of 66 seropositive and 67 seronegative men and women about the impact of an HIV diagnosis upon psychosocial well-being. No significant differences between seropositives and seronegatives were found on any of the psychosocial measures except hopelessness. Nor was there significant variation by disease progression (but this may be due to the restricted size of the sample). The qualitative data are used to illustrate these findings and explore their meaning. It is concluded that, with the exception of a hopeless future orientation, psychosocial disturbance of seropositives tends to be episodic and short-lived and thereby difficult to measure.

Burden of Suicidal Ideation and Attempt among Persons Living with HIV and AIDS in Semiurban Uganda

Although the impact of HIV/AIDS has changed globally, it still causes considerable morbidity and mortality, including suicidality, in countries like Uganda. This paper describes the burden and risk factors for suicidal ideation and attempt among 543 HIV-positive attending two HIV specialized clinics in Mbarara municipality, Uganda. The rate of suicidal ideation was 8.8% (n = 48; 95% CI: 6.70-11.50) and suicidal attempt was 3.1% (17, 95% CI 2.00-5.00). The factors associated with increased risk for suicidal ideation and attempts were state anger (OR = 1.06, 95% CI: 1.03-1.09; p = 0.001); trait anger (OR 1.10, 95% CI 1.04-1.16, p = 0.002); depression (OR 1.13, 95% CI 1.07-1.20, p = 0.001); hopelessness (OR 1.12, 95% CI 1.02-1.23, p = 0.024); anxiety (OR 1.06, 95% CI 1.03-1.09); low social support (OR 0.19, 95% CI 0.07-0.47, p = 0.001); inability to provide for others (OR 0.19, 95% CI 0.07-0.47, p = 0.001); and stigma (OR 2.48, 95% CI 1.11-5.54, p = 0.027). At multivariate analysis, only state anger remained statistically significant. HIV/AIDS is associated with several clinical, psychological, and social factors which increase vulnerability to suicidal ideation and attempts. Making suicide risk assessment and management an integral part of HIV care is warranted.

Lifetime suicidal ideation and attempt are common among HIV+ individuals

BACKGROUND

Estimates of the prevalence of lifetime suicidal ideation and attempt, and risks for new-onset suicidality, among HIV-infected (HIV+) individuals are not widely available in the era of modern combined antiretroviral treatment (cART).

METHOD

Participants (n=1560) were evaluated with a comprehensive battery of tests that included the depression and substance use modules of the Composite International Diagnostic Interview (CIDI) and the Beck Depression Inventory-II (BDI-II) as part of a large prospective cohort study at six U.S. academic medical centers. Participants with possible lifetime depression (n=981) were classified into five categories: 1) no thoughts of death or suicide (n=352); 2) thoughts of death (n=224); 3) thoughts of suicide (n=99); 4) made a suicide plan (n=102); and 5) attempted suicide (n=204).

RESULTS

Twenty-six percent (405/1560) of participants reported lifetime suicidal ideation and 13% (204/1560) reported lifetime suicide attempt. Participants who reported suicidal thoughts or plans, or attempted suicide, reported higher scores on the BDI-II (p<0.0001), and higher rates of current major depressive disorder (p=0.01), than those who did not. Attempters reported higher rates of lifetime substance abuse (p=0.02) and current use of psychotropic medications (p=0.01) than non-attempters.

LIMITATIONS

Study assessments focused on lifetime, rather than current, suicide. Data was not collected on the timing of ideation or attempt, frequency, or nature of suicide attempt.

CONCLUSIONS

High rates of lifetime suicidal ideation and attempt, and the relationship of past report with current depressed mood, suggest that mood disruption is still prevalent in HIV. Findings emphasize the importance of properly diagnosing and treating psychiatric comorbidities among HIV persons in the cART era.

HIV infection and mental health: suicidal behaviour--systematic review

Suicide has long been associated with serious illness generally and HIV specifically. New treatments have affected prognosis in HIV positively, but it is unclear how they impact on suicidal burden (thoughts, self-harm and completions). This review examines all published suicide and HIV data for a definitive account of (1) prevalence of HIV-related suicidality, (2) measurement within studies and (3) effectiveness of interventions. Standard systematic research methods were used to gather quality published papers on HIV and suicide, searching published databases according to quality inclusion criteria. From the search, 332 papers were generated and hand searched resulting in 66 studies for analysis. Of these, 75% were American/European, but there was representation from developing countries. The breakdown of papers provided 12, which measured completed suicides (death records), five reporting suicide as a cause of attrition. Deliberate self-harm was measured in 21, using 22 instruments; 16 studies measured suicidal ideation using 14 instruments, suicidal thoughts were measured in 17, using 15 instruments. Navigating the diverse range of studies clearly points to a high-suicidal burden among people with HIV. The overview shows that autopsy studies reveal 9.4% of deceased HIV+ individuals had committed suicide; 2.4% HIV+ study participants commit suicide; approximately 20% of HIV+ people studied had deliberately harmed themselves; 26.9% reported suicidal ideation, 28.5% during the past week and 6.5% reported ideation as a side effect to medication; 22.2% had a suicide plan; 19.7% were generally "suicidal" (11.7% of people with AIDS, 15.3% at other stages of HIV); 23.1% reported thoughts of ending their own life; and 14.4% expressed a desire for death. Only three studies recruited over 70% female participants (39 studies recruited over 70% men), and six focussed on injecting drug users. Only three studies looked at interventions - predominantly indirect. Our detailed data suggest that all aspects of suicide are elevated and urgently require routine monitoring and tracking as a standard component of clinical care. There is scant evidence of direct interventions to reduce any aspect of suicidality, which needs urgent redress.

Human immunodeficiency virus and depression in primary care: a clinical review

BACKGROUND

Human immunodeficiency virus (HIV)-infected individuals are at increased risk of developing depression. Depressive syndromes in these patients pose a challenge both diagnostically and therapeutically. These syndromes reflect both the presence of preexisting mood disorders and the development of depressive syndromes subsequent to HIV infection.

DATA SOURCES

A search of the literature to 2005 was performed using the PubMed and Ovid search engines. English- and Portuguese-language articles were identified using the following keywords: HIV or AIDS and depression, mental illness, suicide, fatigue, psychiatry, and drug interactions. Additional references were identified through bibliography reviews of relevant articles.

DATA SYNTHESIS

The clinical presentation and differential diagnosis of depressive symptoms in HIV illness and the role of HIV in the development of these conditions are reviewed. Management issues including suicide assessment and treatment options are then discussed, and potentially important pharmacokinetic interactions are reviewed.

CONCLUSIONS

Individuals with HIV show higher rates of depression. This phenomenon may be due to a preexisting psychiatric disorder or to the HIV infection. Untreated depression symptoms may lead to non-compliance with drug regimens or increased high-risk behaviors. Given the adverse sequelae of untreated depressions in HIV illness, identification and management of depression are integral components of comprehensive HIV care.

Protective factors against suicide attempt risk among African American women experiencing intimate partner violence

Protective factors (hope, spirituality, self-efficacy, coping, social support-family, social support-friends, and effectiveness of obtaining resources) against suicide attempts were examined in economically, educationally, and socially disadvantaged African American women (100 suicide attempters, 100 nonattempters) who had experienced recent intimate partner violence. Significant positive associations were found between all possible pairs of protective factors. Bivariate logistic regressions revealed that higher scores on each of the seven protective factors predicted nonattempter status; multivariate logistic regressions indicated that higher scores on measures of hope or social support-family showed unique predictive value for nonattempter status. Further, the multivariate model accurately predicted suicide attempt status 69.5% of the time. Partial support was found for a cumulative protective model hypothesizing a linear relationship between the number of protective factors endorsed and decreased risk for suicide attempts. Implications of these findings for community-based preventive intervention efforts and future research are discussed.

Pain and psychiatric disorders contribute independently to suicidal ideation in HIV-positive persons

The relationships between HIV-related pain, psychiatric disorders, and suicidal ideation (SI) are not well understood. The presented research investigated the ability of pain, psychiatric diagnoses, coping styles, and locus of control (LOC) to predict SI in 75 HIV-positive persons, using a sequential logistic regression. Reported psychiatric diagnoses included depression, anxiety, and substance abuse disorders. Variance accounted for by these analyses was approximated at 33%, with pain severity independently predicting SI after accounting for psychiatric diagnoses. Coping and LOC did not add significantly to the models. Given the prevalence of pain in this population, these results underscore the importance of assessing and treating pain and SI in persons with HIV.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Suicide attempts among gay and bisexual men: lifetime prevalence and antecedents

OBJECTIVES

We examined lifetime prevalence of suicide attempts and psychosocial correlates in a large population-based sample of men who have sex with men (MSM).

METHODS

A telephone probability sample of US urban MSM (n = 2881) were interviewed between November 1996 and February 1998.

RESULTS

Twenty-one percent had made a suicide plan; 12% had attempted suicide (almost half of those 12% were multiple attempters). Most who attempted suicide made their first attempt before age 25. Although prevalence of parasuicide (i.e., attempted suicide) has remained constant across birth cohorts, mean age at initial attempts has declined.

CONCLUSIONS

MSM are at elevated risk for suicide attempts, with such risk clustered earlier in life. Some risk factors were specific to being gay or bisexual in a hostile environment.

Suicidal behaviour in people with HIV/AIDS: a review

OBJECTIVE

To review the existing literature on suicidal behaviour in people with HIV/AIDS infection.

METHOD

A search on the Index Medicus/MEDLINE database was performed, for articles that investigated and/or reviewed suicidal behaviour in people with HIV at any stage of the illness. Only articles written in English were used in this review.

RESULTS

Most studies have been done on homosexual/bisexual groups, with little data available for heterosexual populations or women. Studies show an increased rate of suicidal ideation, suicide attempts and completed suicide in individuals with HIV/AIDS. Of note, there is a high prevalence of psychiatric illness and substance abuse in those with suicidal behaviour.

CONCLUSIONS

The increased rate of suicidal behaviour in HIV-infected persons is consistent with findings in other medically ill groups with chronic, life-threatening disorders. However, assessment of any possible direct effect of HIV/AIDS on suicidal behaviour is confounded by methodological limitations of many of the studies. More longitudinal studies encompassing other affected groups including heterosexual populations and women are needed to elucidate the relationship between suicidal behaviour and HIV/AIDS.

Hope, despair and hopelessness in living with HIV/AIDS: a grounded theory study

BACKGROUND

Hope, despair or hopelessness have been detected in several research reports as important elements of the lives of persons living with human immunodeficiency virus (HIV) (PLWH) or acquired immunodeficiency syndrome (AIDS) (PLWA). However, there is an obvious gap in the literature suggesting a need to study the overall dynamics of hope (including both hope and despair or hopelessness) along the HIV spectrum from PLWHs' and PLWAs' perspective.

AIM

The purpose of this study was to describe the dynamics of hope in living with HIV/AIDS.

METHODS

The data were collected through interviewing 10 PLWHs/PLWAs and analysed using a grounded theory method.

FINDINGS

The dynamics of hope is a multifaceted and complex combination of 'hope', 'despair' and 'hopelessness'. It comprises balancing between 'believing life to be worth living at the present and in the future', 'losing one's grip and sinking into narrowing existence vs. fighting against sinking' and 'giving up in the face of belief in nonexisting future'. A dynamic alternation between hope, despair and hopelessness takes place in the presence of factors that contribute to the 'folding' and 'unfolding' possibilities in everyday life. Factors contributing to the folding possibilities include 'losing', 'fear', 'uncertainty', 'problems in care', 'HIV/AIDS in close ones', 'difficulties in relationships' and 'negative public images and attitudes concerning HIV'. Factors contributing to the unfolding possibilities are 'constructive life experiences', 'wishing not to have HIV while uncertain', 'constructive relationships', 'ability to control one's life', 'finding the meaning of life and zest for life', 'caring', 'noticing one's improved health and the continuance of life', 'increasingly positive attitudes concerning HIV-positive people' and 'protection by law'.

CONCLUSIONS

The dynamics of hope discovered in this study present new conceptualization, where hope, despair and hopelessness are viewed in relation to each other. The emerged definitions may be used in clinical practice to identify these phenomena in individuals with HIV/AIDS. The discovered factors contributing to the folding and unfolding possibilities can be used in clinical practice to help the individuals along the dynamics of hope.

Theoretical perspectives on suicide in gay men with AIDS

Suicide among gay men with AIDS constitutes a significant theoretical and practical problem. In order to understand this problem it is necessary to consider the specific circumstances that surround these individuals. Whilst there are many theories of suicide with which to address the problem, few are able to capture the special context within which gay men with AIDS live. This article explores three broad concepts from the theoretical literature on suicide that have explanatory potential in this unique context. The three concepts are: the search for meaning in the midst of suffering, Shneidman's [Shneidman, E., 1985. Definition of Suicide. John Wiley, New York] notion of unendurable psychological pain, and hopelessness. This article attempts to demonstrate how these three concepts can incorporate the experiences of gay men with AIDS and contribute to understanding the problem of suicide in this population.

Assisted suicide, depression, and the right to die

The debate surrounding the legalization of assisted suicide continues despite a limited body of empirical research. Relatively few studies have addressed interest in assisted suicide or the desire for hastened death (rather than approval of legislation) among medically ill patients, and this literature is plagued by methodological limitations. In general, this research has demonstrated a significant association between depression and desire for death; however, the magnitude of this association is unclear. Nevertheless, psychological and social factors have typically appeared more influential in determining patients' desire for death than physical symptoms such as pain. The impact of these findings on future legislative efforts to legalize assisted suicide is discussed.

Complementary medicine and HIV infection

The social role of alternative medicine is critical in empowering the large proportion of HIV-positive patients who choose to use nontraditionally prescribed medicines. Working toward an open scientific dialogue with HIV-related complementary therapies is a worthy goal for all providers.

Managing depression among people with HIV disease

Many people with HIV suffer from depression, which responds to antidepressants, counseling, education, and cognitive strategies. Untreated depression hinders treatment compliance and increases risk of suicide. Management and complications of major depression are described. The evaluation of rational suicide is examined. Clinicians who treat this population need to respond therapeutically to patients with depression and suicidal ideas.

Emotional distress in men with life-threatening illness

This descriptive survey explored the relationship of health status, functional status, stressful life events, stress resistance resources and emotional distress in 60 men with life-threatening illness (N = 30 with cancer and N = 30 with AIDS). Sixty-two percent met CES-D criteria for clinical depression. This study's results supported the hypotheses that poorer functional status and greater negative stressors are associated with both higher levels of hopelessness and depression. Twenty-four patients constituted a group with severe emotional distress. This group was significantly different from the less vulnerable group with poorer functional status (KPS), a greater number and severity of negative stressors, less satisfaction with social support, and less hopefulness.