Research report
Suicide probability and psychological morbidity secondary to HIV infection: a control study of HIV-seropositive, hepatitis C virus (HCV)-seropositive and HIV/HCV-seronegative injecting drug users

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Abstract

Background: Suicide ideation and psychological morbidity among HIV-positive patients has been the object of intense research. No study has investigated this area among injecting drug users (IDUs) infected with HIV and those infected with the hepatitis C virus (HCV), which has the same patterns of transmission of the HIV and may favour HIV replication and, possibly, HIV disease progression. Methods: In order to examine the prevalence and characteristics of suicide ideation and psychological morbidity associated with HIV and HCV infection in IDUs, a sample of HIV+ (n=81), HIV−/HCV+ (n=62) and HIV−/HCV− (n=152) subjects completed the Suicide Probability Scale (SPS), The Brief Symptom Inventory (BSI) and the Hospital Anxiety and Depression Scale (HADS). Results: No difference was found between the groups as far as the mean scores on SPS and the risk of suicide (no-low risk category: 70.7% HIV+, 56.09% HCV+, 65.6% HIV−/HCV−). Estimated psychological morbidity (BSI) (26.9% HIV+, 27.1% HCV+, 25.4% of HIV−/HCV−) and BSI and HADS scores were comparable across the groups. Conclusions: Suicide ideation, psychological morbidity and anxiety and depression symptoms seemed not to be directly influenced by HIV-serostatus. Careful assessment of psychological symptoms and suicide ideas among IDUs, as a vulnerable segment of population at risk of HIV and HCV infections, needs to be routinely carried out in clinical settings.

Introduction

Suicide has been reported to be an important concomitant of HIV infection. Although early studies showed a higher risk of suicide and/or suicide attempts among HIV-seropositive (HIV+) patients, postulating an ‘inducer’ effect of HIV-infection on suicide, more recent data suggested a possible ‘accelerator’ role of the disease in favouring suicide gestures in those who have psychological disorders antedating HIV (for reviews, see Bellini and Bruschi, 1996; Catalan and Pough, 1995). In fact, it has been found that psychiatric morbidity and suicide ideation are quite comparable among HIV+ patients and HIV-seronegative (HIV−) subjects at risk of HIV infection, such as gay men (Perry et al., 1990; Rosenberger et al., 1993), and that in the majority of the cases, suicide attempts antedated HIV infection (Dannenberg et al., 1996; Kelly et al., 1998). In contrast with these findings, other studies indicated that suicide ideation is higher among HIV+ than HIV− subjects (Cochand and Bovet, 1998) and that history of deliberate self-harm conducts pre-HIV infection is not necessarily associated with attempted suicide after HIV notification (Simoni et al., 1998).

However, suicide ideas are frequent among HIV+ patients and analysis of potential risk factors associated with suicide proneness represents an important clinical area on which to concentrate attention. A 27.1 and 16.3% prevalence of suicidal thoughts 1 week after notification and 2 months later, respectively, were showed by Perry et al. (1990) in a large sample of subjects, most of them homosexuals. Schneider et al. (1991a) found that 27% of HIV-infected gay and bisexuals had suicidal ideation over the previous 6 months, while Judd and Mich (1996) reported a current 40% prevalence of suicidal thoughts among 100 homosexual or bisexual patients. In contrast with these high figures, lower percentages of suicidal ideas, ranging from 3 to 6%, were found in other studies (Riccio et al., 1993).

Less data are available on this topic among injecting drug users (IDUs), although it has been shown that this population is at a higher risk of psychopathology than HIV+ gay men, heterosexuals and patients with haemophilia (Cazzullo et al., 1990; Gala et al., 1993). As far as general psychiatric morbidity is concerned, some authors reported a comparable prevalence of psychiatric disorders among HIV+ and HIV− IDUs (Lipsitz et al., 1994; Davis et al., 1995), while other studies indicated higher levels of psychopathology in HIV-infected than non-infected IDUs (Pakesch et al., 1992; Hestad et al., 1994, Dew et al., 1997). With reference to suicidal behaviour, Gala et al. (1992) showed that a life-time history of psychiatric disorders and previous deliberate self-harm, rather than HIV infection per se, were the most significant predictors of current suicide attempts in HIV+ IDUs both at notification and at a distance of time. Furthermore, it has been shown that notification of seropositivity did not account for an increased risk of suicide (Van Haastrecht et al., 1994) and that deaths due to overdose or suicide were comparable among HIV+ and HIV− IDUs (Mezzelani et al., 1998).

The problem of suicide ideation and psychosocial morbidity is made more complex by the fact that IDUs are also at a higher risk of being seropositive for the hepatitis C virus (HCV), which has similar patterns of transmission as HIV, such as sharing injecting equipment and having unprotected sex (Galeazzi et al., 1995). In fact, a high a percentage of HIV+ are also seropositive for the HCV (HCV+) (Cattaneo et al., 1999) and recent evidence indicated that co-infection with HCV seems to favour HIV replication and, possibly, disease progression (Haydon et al., 1998; Piroth et al., 1998). Nevertheless, no study investigated and compared suicide ideation and psychological morbidity among IDUs infected with the HIV (with or without concomitant HCV infection) and those infected with the HCV only. According to the few data available, it has been demonstrated that HCV+ IDUs present high levels of depression (Johnson et al., 1998).

The aims of this control study were 2-fold: (i) to explore the prevalence and characteristics of suicide ideation and psychological morbidity among Italian HIV+ IDUs, and (ii) to compare these features with those obtained from HIV−/HCV+ and HIV−/HCV− IDUs.

Section snippets

Subjects

This study is part of a more general investigation of psychosocial implications of HIV infection, carried out in Ferrara, North-East Italy (Grassi et al., 1995, Grassi et al., 1998, Grassi et al., 1999). The study population consisted of a convenience sample of IDUs assisted by the out-patient service, Division of Infectious Diseases, St. Anna Hospital in Ferrara for HIV infection (HIV+ group), HCV infection (HCV+ group) or HIV/HCV risk (HIV−/HCV− group). Criteria for inclusion of HIV-infected

Sample characteristics

Two hundred and ninety-five IDUs took part in the study. The population was representative of the entire populations followed by the service, with only 18 declining participation. No difference was found between participants and non-participants with regard to socio-demographic characteristics. The HIV+ group consisted of 81 subjects (63 males, 77.7%, and 18 females, 22.3%). Thirty-three subjects (40.7%) were in Center for Disease Control (CDC) stage II, 43 (53.1%) in CDC stage III, and five

Discussion

To our knowledge this the first study examining current suicidal ideation and psychological morbidity among HIV-positive IDUs in comparison with subjects infected with the HCV.

A first general result of the study was that, globally, about one third of HIV-infected patients reported thoughts and desires of death that fitted them in mild–moderate to high risk categories. These results confirm data of other studies showing a 25–30% prevalence of suicidal ideas among HIV-infected patients,

Acknowledgments

The study was supported by funds from the University of Ferrara (Psychiatry/HIV infection Project 1996–97). The authors are indebted to Paul Packar for the revision of the manuscript.

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