Background
Depression is one of the most common mental health diagnoses among people living with HIV/AIDS (PLWH) [
1]. The lifetime prevalence of depression among PLWH was estimated between 22% - 45% [
2]. The 12-month prevalence of major depression was 22% in a nationally representative cohort of PLWH receiving care in the U.S. [
3]. Although the rate among PLWH may or may not be different from other adults in the same community, it seemed to be lower for the general population [
1,
4,
5]. The prevalence rate for major depression was 6.6% among adults participating in a U.S. representative household survey [
6].
Studies on changes in depressive symptoms found mixed results. Although one study found that the mood was stable regardless of illness progression [
7], another study showed that depression decreased over a two-year period after receiving ART [
8]. Others showed that depression did not change until the period of 12–18 months before AIDS diagnosis when depression started increasing significantly [
9‐
11].
Depression was found to be associated with HIV progression and mortality among PLWH [
12‐
15]. In addition, PLWH with depression were more likely to have poor medication adherence [
16‐
19]. Those with depression and poor adherence had a mortality risk of six times higher than those without depression [
20]. Effective treatment of depression also improved adherence to antiretroviral therapy (ART) [
21]. Other correlates of depression included age, gender, substance abuse, perceptions of HIV related stigma, social support and social isolation [
1,
22‐
27].
Vietnam is a Southeast Asian country with over 90 million people. It is estimated that 197,335 people were living with HIV/AIDS in 2011 and 263,317 in 2015 [
28]. Because HIV is usually linked to drug use and commercial sex workers [
29,
30], which are illegal and culturally unacceptable in Vietnam, PLWH are likely to experience mental health problems, particularly depression, due to stigma and discrimination [
31]. Social support and access to mental health care for PLWH are also insufficient in Vietnam [
32‐
34].
Understanding about depression among PLWH in Vietnam is limited. In our literature review, we found only two cross-sectional studies on depression among PLWH in Vietnam. One showed that depression prevalence among HIV-infected men over a month was 18.7%, which seems to be much higher than the general population of Vietnamese men [
35]. The second article found an inverse association between ART adherence and depression [
36].
This study, therefore, aims to address this gap by (1) examining changes in depression symptoms among PLWH at An Hoa clinic in Ho Chi Minh city (HCMc), Vietnam; and (2) identifying correlates of depression. Findings from this study will improve knowledge about depression among PLWH in Vietnam and help design effective interventions.
Results
Characteristics of the sample
At baseline, the average age of participants was 33 years, ranging from 18 to 59 years; about 62% were from 31–40 years (Table
1). Female made up 26.86% of the sample. A majority were “Kinh people” (85.54%); did not go to senior high school (78.10%); and had a religion (88.43%). About half were living with a spouse (52.89%); and had a co-morbidity (51.65%). A quarter (24.79%) had no income. Over one-third (40.08%) lived in economically disadvantaged household. About 70.66% adhered to treatment. The mean of the social relationship score was 12.33. Of 242 participants, 61.98% (150 participants) had depression and 34.71% (84 participants) had major depression. CESD mean score was 19.91.
Table 1
Characteristics of the samples
Age |
18–30 | 67 | 27.69% | 67 | 28.63% |
31–40 | 151 | 62.40% | 143 | 61.11% |
41-59 | 24 | 9.92% | 24 | 10.26% |
Gender (Female) | 65 | 26.86% | 64 | 27.35% |
Ethnicity (Kinh people) | 207 | 85.54% | 200 | 85.47% |
Education (Below Grade 10) | 189 | 78.10% | 183 | 78.21% |
Religion (Yes) | 214 | 88.43% | 209 | 89.32% |
Marital status (Live with spouse) | 128 | 52.89% | 123 | 52.56% |
Individual income status |
Regular | 106 | 43.80% | 108 | 46.15% |
Irregular | 76 | 31.40% | 69 | 29.49% |
No income | 60 | 24.79% | 57 | 24.36% |
Household economy (economically disadvantaged) | 97 | 40.08% | 86 | 36.75% |
Co-morbidity (Yes) | 125 | 51.65% | 125 | 53.42% |
Adherence (Yes) | 171 | 70.66% | 194 | 82.91% |
Social relationship score | 242 | 12.33 (2.78) | 234 | 12.33 (2.91) |
CESD mean score (SD) | 242 | 19.91 (10.33) | 234 | 20.56 (10.23) |
CESD cut-off (≥16) |
Yes | 150 | 61.98% | 148 | 63.25% |
No | 92 | 38.02% | 86 | 36.75% |
CESD cut-off (≥23) |
Yes | 84 | 34.71% | 99 | 42.31% |
No | 158 | 65.29% | 135 | 57.69% |
The number of participants at T1and T2 was, respectively, 242 and 234. Chi-square test showed that differences in demographic characteristics at the two time points were not significant (p = 0.904 for gender, p = 0.959 for age groups, p = 0.983 for ethnicity, p = 0.978 for education level, and p = 0.759 for religion).
Changes in depressive symptoms and correlates
Model 1 with CESD cut-off of 16 showed that participants were not more likely to have depressive symptoms at T2 compared to T1 (OR = 1.15,
p > 0.05). Model 2 with CESD cut-off of 23 showed that odds of having major depression at T2 compared to T1 was 1.6 (
p < 0.01) (Table
2).
Table 2
GEE for binomial models with CESD cut-off of 16 and 23
Time 2 vs. Time 1 | 1.15 | (0.86, 1.53) | 1.60 | (1.13, 2.24)** |
Age |
(18–30) vs. (31–40) | 0.87 | (0.43, 1.72) | 0.63 | (0.32, 1.24) |
(18–30) vs. (41–59) | 0.72 | (0.24, 2.22) | 0.38 | (0.14, 1.06) |
(31–40) vs. (41–59) | 0.83 | (0.30, 2.33) | 0.60 | (0.28, 1.30) |
Female vs. Male | 1.06 | (0.60, 1.88) | 1.21 | (0.70, 2.11) |
Kinh people vs. others | 0.72 | (0.33, 1.54) | 0.69 | (0.38, 1.28) |
Below vs. Above grade 10 | 1.32 | (0.76, 2.26) | 1.11 | (0.62, 1.99) |
Religion (Yes vs. No) | 0.80 | (0.38, 1.69) | 1.01 | (0.46, 2.19) |
Live with spouse vs. not | 1.02 | (0.64, 1.64) | 1.10 | (0.69, 1.75) |
Individual income status |
Regular vs. irregular | 1.08 | (0.58, 2.04) | 0.63 | (0.34, 1.20) |
Regular vs. no income | 0.84 | (0.41, 1.72) | 0.57 | (0.29, 1.10) |
Irregular vs. no income | 0.78 | (0.35, 1.72) | 0.89 | (0.46, 1.72) |
Household economy (Not economically disadvantaged vs. disadvantaged) | 0.69 | (0.45, 1.04) | 0.90 | (0.55, 1.48) |
Co-morbidity (Yes vs. No) | 1.76 | (1.15, 2.70)* | 1.23 | (0.77, 1.98) |
Social relationship (one unit difference) | 0.76 | (0.69, 0.82)*** | 0.73 | (0.66, 0.81)*** |
Adherence (Yes vs. No) | 0.73 | (0.47, 1.16) | 0.69 | (0.44, 1.09) |
Model 1 found two correlates with depression, co-morbidity and social relationship. Those with a co-morbidity were more likely to have depressive symptoms than those without a co-morbidity (OR = 1.76, p < 0.05). Those with higher social relationship score were less likely to have depressive symptoms than those with lower scores (OR = 0.76, p < 0.001). Model 2 found that only social relationship was associated with depression. Those with higher social relationship score were less likely to have major depression than those with lower scores (OR = 0.73, p < 0.001). In both models, depression was not significantly associated with other variables such as age, gender, and medication adherence (p > 0.05).
Discussion
The findings showed that PLWH were not more likely to have depressive symptoms (CESD ≥ 16) at T2 compared to baseline (model 1) but were more likely to have major depression (CESD ≥ 23) at T2 compared to baseline (model 2). This may suggest that progression from not having depression (CESD < 16) to having depression was not as significant as the progression from having mild to major depression. One possible explanation may be because those who already had mild depression were more likely to live in an unfavorable environment where stigma, lack of mental health services, and insufficient support were more popular than those without depression (i.e., CESD < 16). As environmental effects accumulated, depression symptoms increased. However, this is speculative since data on environment, especially social environment, were not collected. In addition, although it is possible that the effect of previous exposure to the questionnaire may influence responses at T2 (e.g., PLWH responded with more depression at T2 expecting to receive more support), it may not be plausible because differences in depression was not significant in model 1.
Although reliable population comparisons are not available, high prevalence of major depression (34.31%) in the study sample likely indicates that interventions are needed to prevent and control depression among PLWH.
Despite that women were found more likely than men to suffer depression in the general population [
47], the association was less consistent among PLWH [
1,
48‐
50]. In this study, women seemed to have more depression although the association was insignificant. It is worth noting that women made up only 26% of the sample, and so the statistical power to detect differences between the sexes may be limited.
Medication adherence was not associated with depression in this study. This is not consistent with other studies which found that depression was associated with poorer adherence [
16,
17,
36]. This may be due to PLWH’s reactivity, i.e., trying to improve adherence, as they may think that they were under a close supervision when participating in the study. However, it is also worth noting that this study used a stricter definition of adherence by which remembering to take medication was not the only criterion. PLWH needed to revisit the clinic on the appointment date or the next day at the latest. As such, the finding may not be comparable to other studies.
Having a co-morbidity seems to be associated with greater likelihood of depression. Although the association was only significant in model 1 (CESD <16/≥16), the direction of the effect was the same in model 2 (ORs > 1). The effect of co-morbidity on depression is plausible due to the impact of deteriorating physical and mental health and the stress of cost and side-effects related to treatment medication for co-morbidities.
Although depression can be effectively treated among PLWH [
51,
52], interventions should focus not only on treating depression but also treating other co-morbidities. In addition, the finding that social relationship was the strongest correlate with depression in this study emphasized the importance of addressing psychosocial needs of PLWH. Improving social relationship should be included as an essential strategy in future interventions.
Although our study had an appropriate design, used validated measurement tools, and had an adequate sample size, it has some limitations. First, this study was conducted in only one clinic so generalizability was limited. Second, depression were self-reported so they may not be as accurate as clinical diagnosis. However, as the same self-reported tool was used at both T1 and T2, the effect of this bias would be limited. Third, although the instruments were validated, recall bias is possible in self-reported data. Fourth, as depression treatment was not controlled for, it is possible that some received depression treatment elsewhere during the three-month study period. However, the chance was minimal because depression care was very limited in Vietnam [
34]. Mental health services, even in big cities such as Hanoi and Ho Chi Minh city, do not focus on depression but mainly on schizophrenia, bipolar disorder, and epilepsy [
34]. Finally, since this is an observational study without a comparison group, many factors which could affect depression could not be fully controlled.
Conclusion
PLWH were not more likely to have depression (<16/≥16) at T2 compared with baseline but more likely to have major depression (<23/≥23) at T2 compared with baseline. Social relationship was found to be strongly associated with depression. Associations between age, individual income status, and co-morbidity were not decisive. Gender, ethnicity, education, religion, marriage, household economy, and adherence were not correlates.
Our study was a response to a call for more studies on HIV and depression in Asian countries [
53]. It contributes to understanding of depression among PLWH receiving ART in Asia, and particularly in Vietnam. Our findings emphasize the need for interventions addressing mental health among PLWH in Vietnam. This study can be useful in designing and building effective interventions to prevent and control depression. Future research should include larger and more diverse samples to increase generalizability; control effects associated with other factors such as previous exposure to the questionnaire; improve depression diagnosis by clinical assessment; and evaluate severity of co-morbidities to increase the strength of conclusions.
Acknowledgement
The authors thank the reviewers and Associate Professor Emeritus Trude Bennett University of North Carolina for reviewing the manuscript and for their valuable comments.