Depression and Suicidal Ideations among Older Persons Living with HIV/AIDS in Mbarara City, Southwest Uganda ()
1. Introduction
Depression is one of the most common mental disorders, usually characterized by persistently low mood, loss of interest in pleasurable activities, feelings of hopelessness, disturbed sleep, poor concentration, worthlessness, failure, and self-blame [1] . In addition, depression presents with several somatic symptoms that can easily mimic a physical illness [2] . When depression occurs in the context of a physical illness, it may be challenging to distinguish it from the symptoms of a physical illness [3] . These chronic medical diseases are prevalent among older adults 50 years and above [4] . The most common physical illnesses associated with depression are chronic medical diseases, including cancer, cardiovascular, metabolic, inflammatory, neurological disorders, and HIV [3] . HIV and depression are prevalent among older populations in sub-Saharan Africa (SSA), and the prevalence ranges between 6% and 59% based on a systematic review of 25 studies about depression [5] . The prevalence of depression among older adults was more among women than men [6] [7] [8] .
Depression is one of the strongest risk factors for suicide and suicidal behaviors among persons living with HIV [9] . Several factors have been identified to be associated with suicidal behaviors, including HIV encephalitis, other psychiatric illnesses, substance use, previous attempts, recent HIV infection (past two years), and transmission from none sexual means such as injection drug use [10] . Other factors that may increase the risk of depression and suicidal behaviors among older individuals include: ageism and stigma, loneliness, decreased social support, neurological changes, declining health, fatigue, changes in appearance, financial distress, and loss of peers [11] . Depression among older individuals living with HIV in sub-Sahara Africa has also been reported to be associated with those with declining socio-economic status, increasing disability scores, decreasing mean grip strength, back pain, urban residency, having an adult caregiver, receiving government grants, and hypertension [6] [8] .
Most studies (13 studies) about the mental health and well-being of older persons living with HIV were from Uganda [5] . However, few of these studies are specifically about depression and suicidal behaviors. The prevalence of depression and suicidal behaviors among older persons living with depression in Uganda ranges between 9.2% to 14.3% [8] [12] [13] [14] . Most of these studies have been conducted in the central part of the country—a region that has consistently had a higher prevalence of HIV, contributing approximately 25% of the cases in 2021/2022 [15] . However, individuals from the south-western region (have the third highest prevalence of HIV/AIDS) of the country have consistently been reported to have more viral load suppression (currently at 83%). They may have older individuals living with HIV/AIDS [15] , due to the continuous increase in survival among older persons with good ARV adherence indicators such as viral load suppression [11] . In the south western region, especially Mbarara district (7.9% higher than the national prevalence), was ranked among the districts with the highest prevalence of HIV/AIDS infected individuals [16] . For better service provision among older individuals living with HIV, this study aimed at determining the prevalence of depression suicidal ideations, and their associated factors among the elderly living with HIV/AIDS and accessing care at selected healthcare facilities in Mbarara city, southwestern Uganda.
2. Methods
2.1. Study Design, Setting, and Population
This study was approved by Mbarara University of Science and Technology research ethics committee. It was a cross-sectional study among older persons aged 60 years and above living with HIV/AIDs in Uganda accessing health care services in purposively selected health facilities in Mbarara city, Southwestern Uganda. An older person is defined by the United Nations as a person who is over 60 years of age. The health facilities involved were TASO Mbarara, Mbarara City Health Centre IV, and Nyakayojo Centre IIIs.
2.2. Sample Size Calculation and Sampling
According to 2020 clinical records, the four combined Health facilities had 603 individuals living with HIV/AIDS aged 60 years and above. i.e., TASO Mbarara = 426, Mbarara City Council HC IV = 156, and Nyakayojo health centre III = 11 clients. The study was conducted from May 2021 to December 2021.
The sample size was determined using T Yamane [17] formula of sample size determination which states that:
where n is the sample size, N is the total population, and e is the marginal significance level at 0.05. Using the formula above, the calculated sample was 241 participants with a non-acceptancy level of 10%, a margin error of 0.1, a total sample of 265 was considered. The sample was distributed based on a probability proportional to the size of the number of potential participants per facility, i.e., 185, 70, 5, and 5 for TASO Mbarara, Mbarara City Council health center IV, and Nyakayojo HC III, respectively. The participants were recruited consecutively. Individuals who were critically ill (as determined by the research assistants with previous medical training), and unable to sustain a 45-minute interview were excluded from the study.
Selection criteria
We enrolled elderly patients living with HIV/AIDS, aged 60 years and above accessing services at, The AIDS Support Organization (TASO) Mbarara and Mbarara City Council H/C IV, Nyakayojo and Kakoba health centre IIIs who consented consent to participate in the study. Lists of clients aged 60 years and above were made on each clinic day from the study sites and simple random sampling was used select them.
2.3. Data Collection
The questionnaire captured participants’ socio-demographic characteristics, clinical characteristics and data on the prevalence of depression, and suicidal ideation was captured using the Patient Health Questionnaire-9 (PHQ-9). For consistency, the PHQ-9 was researcher administered since some participants may not be able to read and write. The questionnaire was made in English but translated into the local language—Runyankole (language used by the individuals in the study area). For consistency of the translation, back-translation was employed to confirm that the meaning was not lost.
The PHQ-9 is a nine-item tool validated in Uganda and has excellent psychometric properties among individuals in Uganda [18] . The PHQ-9 was previously used in Uganda among people living with HIV [19] [20] [21] . Using the PHQ-9 scale, the cut-off points are: 1 - 4 minimal depression, 5 - 9 mild depression, 10 - 14 moderate depression 15 - 19 moderately severe depression and 20 - 27 severe depression. Depression is diagnosed when one scores 10 and above. In addition, as used in previous studies in the country, a score of one, two, or three on Item 9—“Thoughts that you would be better off dead, or of hurting yourself”, was used to indicate the presence of suicidal ideation [22] .
Statistical Analysis
Stata version 17, StataCorp LLC 4905 Lakeway Drive College Station, Texas, USA was used for data analysis. Means and standard deviations were used to summarize continuous variables, while percentages and frequencies were used to summarize categorical variables. Chi-square tests were performed to identify differences between depression or suicidal ideations, and independent study variables. Logistic regression analysis was used to determine associations between independent variables of interest and depression, or with suicidal ideation. Two separate logistic regressions based on backward stepwise methods for factors significant on bivariate analysis were conducted to determine the factors associated with depression and the factors associated with suicidal ideation. Factors significant at p < 0.1 at bivariate logistic regression were considered for inclusion in a multivariable level analysis. Factors with a p value < 0.05 were kept in the final multivariable model and all effect measures were presented with a significance level of 5% with a 95% CI.
3. Results
A total of 265 older people living with HIV/AIDS were included in the final analysis. The age of the participants ranged from 60 to 84 years, with a mean of 64.2 (SD ± 5.1) years. Most of the participants were females 150 (56.6%) (Table 1).
3.1. Prevalence of Depression
Approximately 22 (8.3%) of the participants had depression based on the PHQ-9 cut-off score of 10 out of 27. The median depression symptoms score was 3 [interquartile range (IQR) = 6]. Two out of five study participants had minimal symptoms for depression (40%, n = 106/265).
3.2. Prevalence of Suicidal Ideation
A total of 32 participants (12.1%) reported suicidal ideation and all those with moderate severe depressive symptoms had suicidal ideation. There was a statistically significant correlation between severity of depression and having suicidal ideation (χ2 = 62.04, p < 0.001) (Figure 1).
3.3. Relationship between Depression and Risk Factors
Depression (at a cut-off of 10) was significantly higher among older persons who; 1) stay with two or more family members compared to those who stay with none or one (29.1% vs. 0.0%, χ2 = 8.81, p = 0.032); 2) whose family members do not respect them than those who did (31.3% vs. 6.6%, χ2 = 12.2, p <0.001); 3) currently have any problem with ARVs (21.1% vs. 6.8%, χ2 = 4.96, p = 0.026); 4) currently have a drug companion (11.7% vs. 5.0%, χ2 = 3.80, p = 0.051); and 5) visited the health facility and not get attended to (14.8% vs. 6.2%, χ2 = 4.31, p = 0.038) (Table 1(a) and Table 1(b)).
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Figure 1. Severity of depression and suicidal ideation among older persons living with HIV/AIDS in Mbarara.
3.4. Factors Associated with Depression among Older Persons Living with HIV at Bivariate Analysis
Logistic regression at a bivariate level revealed that depression was significantly associated with the number of family members the participant stays with. Participants who stayed with 3 or more family members were 69% less likely to develop depression (UOR = 0.31, 95% CI (0.12 - 0.77), p = 0.012) compared with respondents who stays with less than 3 members in the family, having family members who do not give respect to the participants that is participants who were not respected by their family members were 6.4 times more likely to develop depression symptoms compared to those whose family members give them respect (UOR = 6.42; 95% CI (1.99 - 20.74); p = 0.002); Participants who had no problems with ARVs were 73% less likely to develop depression symptoms compared to participants who had problems with ARVS (UOR = 0.27; 95% CI (0.08 - 0.92); p = 0.036) and participants who visited the health facility and were attended to were 62% less likely to develop depression symptoms compared with those who visited the health facility and weren’t attended to (UOR = 0.38; 95% CI (0.15 - 0.97); p = 0.044). Factors associated with suicidal ideation include: Participants who earned an average monthly income of UGX 100,000 and above were 68% less likely to develop suicidal ideation compared to those earned an average monthly income of less than UGX 100,000, also participants who often do not interact with their family members were approximately 4 fold more likely to develop suicidal ideation compared to those who often interact with their family members. The results further revealed that if the spouse of the respondents make the economic decision then the participants were 3.6 times more likely to develop suicidal ideation (UOR = 3.6; 95% CI (1.02 - 12.66); p = 0.046); again if the spouse controls the resources then the participants were 3.68 times more likely to develop suicidal ideation (UOR = 3.68; 95% CI (1.04 - 13.01); p = 0.043); Participants who visited health facility and were attended to were 59% less likely to develop suicidal ideation related to participants who visited the health facility and were not attended to (UOR = 0.41; 95% CI (0.02 - 0.93); p = 0.032), and participants who visited the health facility and were not delayed being attended to were 56% less likely to develop suicidal ideation compared to those who visited the health facility and were delayed to be attended to (UOR = 0.44; 95% CI (0.2 - 0.96); p = 0.038); other factors were not statistically significant as demonstrated in Table 2.
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Table 2. Bivariate logistic regression analysis of factors associated with depression, and factors associated with suicidal ideation in older persons living with HIV.
3.5. Factors Associated with Depression among Older Persons Living with HIV at Multivariable Analysis
In the adjusted analysis, older persons living with HIV/AIDS who stay with three or more persons in a home were 65% less likely to develop depression than those who stayed with less than 3 family members (AOR = 0.36; 95% CI (0.13 - 0.95); p = 0.04); and participants currently do not have problems with taking their ARVS were 77% less likely to develop depression symptoms compared with those who experience problems with ARVS (AOR = 0.23; 95% CI (0.06 - 0.89); p = 0.034).
Results further revealed factors associated with suicidal ideation. The average income of the participant associated with suicidal ideation. Participants who earned a monthly income of UGX 100,000 and above were 74% less likely to develop suicidal ideation compared to those earned less than UGX 100,000 (AOR = 0.26; 95% CI (0.07 - 0.99); p = 0.048). Other factors were not statistically significant as portrayed in (Table 3).
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Table 3. Multivariable logistic regression analysis of factors associated with depression and suicidal ideation.
*: Using Uganda Exchange rates as of July 3, 2023.
3.6. Factors Associated with Suicidal Ideation among Older Persons Living with HIV
Suicidal ideations were significantly higher among older persons 1) who did not often interact with their family members; 2) had their spouse (s) controlling their resources; and 3) who visited the health facility and did not get attended to; 4) who ever visited health facility and had a delay of being attended to; and earned above 100,000 UGX (approximately 27 USD) (Table 3). In the model analysis, the factors with a significant relationship at bivariate analysis, were tested for collinearity and the mean VIF was 3.26. Family member who makes economic decisions for the participant had the highest VIF = 7.06, and this was removed from further model building. The remaining variables were collinear, with all individual VIF below 2, and mean VIF of 1.31. The final model had goodness of fit, with a p-value of 0.757. The factors associated with having suicidal ideations, was having their spouse controlling their resources.
4. Discussion
This study aimed to determine the prevalence of depression, suicidal ideation and associated factors among older persons living with HIV/AIDS at selected health facilities in Mbarara city in southwestern Uganda. We found a depression prevalence was 8.3% and suicidal ideation was 12.1%. The likelihood of depression reduced when the older person living with HIV stayed with three or more people and had no problems with their current ARV regimen. However, the likelihood of suicidal ideations decreased when the individual earned more than 100,000 UGx.
The prevalence of depression in the present study (8.3%) was within the range of other findings from similar population in SSA (6% - 59%) [5] . However, the prevalence in the present study was lower compared to studies in SSA that used the same psychometric tool (PHQ-9) and the same cut-off (10) (i.e., 16% - 45%) [5] . The lower prevalence may be attributed to the time when the studies were conducted, i.e., the current study operating in an environment where recommendations from the previous studies may have been implemented. For example, having mental health services such as counselling incorporated with HIV programs and training of health workers in HIV clinic to screen, manage, and refer individuals with depression and other mental health conditions for professional psychiatry care [8] [12] . In addition, study conducted in a region with good viral load suppression [15] , thus less complication due to HIV virus such as encephalitis, and opportunistic infection that may present with mental health complications. No wonder, individuals who had no concerns or issues with their ARVs in the present study were less likely to have depression. Also, the study was conducted during the COVID-19 pandemic, a period that had more people focused on their mental wellbeing following heightened numbers of individuals affected by mental health conditions such as depression [22] [23] [24] ; and could have had better approaches to self care and mental wellbeing. Despite the lower prevalence than previous studies, the prevalence of depression among older persons with depression is still high. We recommend more emphasis on mental health care integration into HIV care packages. In addition to promoting holistic multi-disciplinary care team approach involving mental health professionals such as psychiatrists and psychologists, to mitigate and manage depression and its complications, as well as mitigating the associated risk factors.
In the present study staying with more family members was associated with reducing the likelihood of depression among older persons living with HIV. Family is a major protective factor for depression in Uganda due to the integral roles played by family including social, emotional, financial, and physical support [25] [26] . Having family support from several members may help older individuals stay stimulated due to keeping track of the various individuals in their lives. Also, the family members may encourage the older person to adhere to medication and support them in having a good nutrition through cooking for them and assistances with other activities of daily living. Loneliness has consistently been reported to be a great challenge to older persons, especially those with chronic conditions, such as HIV [27] . Therefore, having many family members staying with the older person living with HIV may mitigate loneliness.
In the present study 12.1% of older persons living with HIV had experienced suicidal ideations. This was relatively more than 7.8% among older person in Entebbe, Uganda [28] . As identified by the current study, the difference may be due to the increase in economic hardship over time. Thus, individuals earning less than 27 USD per month have higher likelihood of depression. These individuals may not be able to afford the current living standards and may experience multiple challenges related to poverty. For example, they may not afford good nutrition, transport to health facilities to collect ARV medications, ability to support a large family or support structure, which may lead to depression and may not afford the cost of medications to manage depression or other co-infections. Many individuals aged 65 and above have retired from the common economic activity, i.e., farming which is not accompanied by any pension, and have only supplementary government aid that is less than 10 USD per month [29] . However, this aid is only given to individuals who are over the age of 80 [29] . Providing adequate financial assistance to older persons in Uganda to an amount more than 27 USD may be helpful in reducing the burden of suicide in this vulnerable population. In addition, the government should develop innovative approaches to reduce poverty among older individual as recommended by Byaruhanga and Debesay, 2021 [30] .
5. Limitations
This was a cross-sectional study with a small sample size from one region of the country and causality and generalisability to the whole country cannot be inferred. We recommend future studies to involve multinational, longitudinal, large sample size populations of older persons living with HIV. Also, the commonly used tool for assessing depression among older individuals in SSA was used in the present study despite the presence of population specific tools such as the geriatric depression scale [5] . Use of a non-population specific tool could introduce bias in the classification of individuals with depression, leading to over or under diagnosis of the condition. We recommend future researchers to use population-based tools in assessing for depression and suicidal behaviors. Lastly, we did not control for the cluster related factors due to the different health facilities which would have introduced bias due to participant selection.
6. Conclusion
Approximately 8 to 12 in 100 older persons living with HIV/AIDS in Uganda have experienced depression or suicidal ideation. Family support was an instrumental factor associated with depression and financial control was associated with suicidal ideation. We recommended strengthening family structures and creating more avenues for financial independence among older persons living with HIV/AIDS to reduce the burden of depression, and suicidal tendencies among this vulnerable population.
Ethical Approval and Consent to Participate
The study was performed in accordance with the international ethical standards of the Declaration of Helsinki. This study was approved by the Mbarara University of Science and Technology Research Ethics Committee and the Uganda National Council for Science and Technology (HS2331ES). All participants provided informed consent prior to participation in the study. Individuals with severe depression and suicidal ideations were referred to Mbarara Regional Referral Hospital for further management.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Funding
Not Applicable.
Consent for Publication
Not Applicable.
Acknowledgements
The authors wish to thank the participants for their time and trust. They also thank the administrators of the four HIV clinics and the leadership of the four study sites in Mbarara City, Uganda for permitting the study to be conducted at their specialised clinics. Special gratitude is extended to the staff working at the specialised HIV/AIDS clinics where the study was conducted. Appreciation is extended to the diligent work of research assistants.
Author Contributions
Conceptualization: Jordan Mutambi Amanyire, Irene Aheisibwe and Godfrey Zari Rukundo, Mark Mohan Kaggwa;
Formal analysis: Waswa Bright Laban;
Methodology: Jordan Mutambi Amanyire, Irene Aheisibwe, Godfrey Zari Rukundo, and Mark Mohan Kaggwa;
Supervision: Irene Aheisibwe, Godfrey Zari Rukundo, and Mark Mohan Kaggwa;
Writing—original draft: Jordan Mutambi Amanyire;
Writing—review & editing: Jordan Mutambi Amanyire, Irene Aheisibwe, Godfrey Zari Rukundo, Mark Mohan Kaggwa.