Clinical Correlates of suicidality among Individuals with HIV infection and AIDS disease in Mbarara Uganda
Abstract and Figures
The association between suicidality and HIV/AIDS has been demonstrated for three decades, but little is know about risk factors that can help understand this association and help identify who is most at risk. Few research studies have been conducted in sub-Saharan Africa, a region that accounts for more than 70% of the HIV global burden. This paper describes clinical risk factors for suicidality among individuals with HIV infection and AIDS disease in Mbarara, Uganda. In this study, suicidality includes both suicidal ideation and suicidal attempts. A cross-sectional survey was conducted with 543 HIV-positive individuals aged 15 years and above, recruited from 2 HIV specialised clinics in Mbarara. Using logistic regression analysis, factors significantly associated with suicidality at 95% confidence interval were identified. The rate of suicidality was 10% (n = 54; 95% CI: 5.00–15.00). Risk factors for suicidality were: perception of poor physical health (OR 2.22, 95% CI 1.23–3.99, p = 0.007), physical pain (OR 1.83, 95% CI 1.01–3.30, p = 0.049), reducing work due to illness (OR = 2.22, 95% CI 1.23–3.99, p = 0.004) and recent HIV diagnosis (OR 1.02, 95% CI 1.01–1.03, p = 0.001). These findings suggest that HIV/AIDS in south-western Uganda is associated with a considerable burden of suicidality. HIV is associated with several clinical factors that increase vulnerability to suicidality. There is need for more appropriate interventions targeting these clinical risk factors, systematic suicide risk assessment and management of suicidal ideation and behaviours in HIV care.
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African Journal of AIDS Research
ISSN: 1608-5906 (Print) 1727-9445 (Online) Journal homepage: http://www.tandfonline.com/loi/raar20
Clinical correlates of suicidality among individuals
with HIV infection and AIDS disease in Mbarara,
Uganda
Godfrey Zari Rukundo, Eugene Kinyanda & Brian Mishara
To cite this article: Godfrey Zari Rukundo, Eugene Kinyanda & Brian Mishara (2016)
Clinical correlates of suicidality among individuals with HIV infection and AIDS
disease in Mbarara, Uganda, African Journal of AIDS Research, 15:3, 227-232, DOI:
10.2989/16085906.2016.1182035
To link to this article: http://dx.doi.org/10.2989/16085906.2016.1182035
Published online: 28 Sep 2016.
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African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Taylor & Francis
African Journal of AIDS Research 2016, 15(3): 227–232 Copyright © NISC (Pty) Ltd
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ISSN 1608-5906 EISSN 1727-9445
http://dx.doi.org/10.2989/16085906.2016.1182035
Introduction
There is substantial evidence indicating that poor physical
health and mental illness are closely related (De Hert et
al., 2011; Rukundo, Musisi, & Nakasujja, 2013; Thornicroft,
2011). Psychological consequences of physical illness
include depression, suicide, anxiety and hopelessness.
In contrast, mental disorders predispose the sufferers to
physical Illness (Jones, Howard, & Thornicroft, 2008).
Although limited information exists on the prevalence of
suicidality among the physically ill, several studies report
that among suicides, 30% to 40% usually have a physical
illness (Druss & Pincus, 2000; Erlangsen, Stenager, &
Conwell, 2015; Mishara, 1998; Wiktorsson et al., 2015).
Increased risk of suicidality has been reported in physical
illnesses that are chronic, terminal or associated with
shame as part of psychological pain (Fässberg et al., 2016;
Goodwin, Marusic, & Hoven, 2003; Timonen et al., 2002).
The relationship between physical illness and suicide cannot
be explained by a single factor (Harwood, Hawton, Hope,
Harriss, & Jacoby, 2006). The physical illnesses that are
associated with an increased risk for suicidality include HIV/
AIDS, certain cancers, epilepsy, cerebral disease, renal
disease, ischemic heart disease, chronic pulmonary disease,
peptic ulcer, prostatic disease, and multiple sclerosis
(Ferreira et al., 2007; Qin, Webb, Kapur, & Sorensen, 2013;
Quan, Arboleda-Florez, Fick, Stuart, & Love, 2002).
Globally, HIV infection is considered a chronic disease
such as hypertension or diabetes. However, in some
countries, HIV is still stigmatised and considered as a
killer disease (Akena, Musisi, Joska, & Stein, 2012; Kelly
et al., 2014; Klopper, Stellenberg, & van der Merwe, 2014;
Kohler et al., 2014; Ky-Zerbo et al., 2014; O’Brien & Broom,
2014; Sulstarova et al., 2015). HIV may affect the central
nervous system, possibly affecting impulse control and
disinhibition of behaviours that may increase the risk of
suicide. Although there is limited evidence, it is possible
that physical symptoms of HIV/AIDS could be responsible
for the increased risk, as with other physical illnesses
(Erlangsen et al., 2015). Despite the low research coverage
in sub-Saharan Africa, it is possible that HIV/AIDS in Africa
maybe associated with a high risk for suicidality (Kinyanda,
Hoskins, Nakku, Nawaz, & Patel, 2012; Ndetei, Khasakhala,
Mutiso, & Mbwayo, 2010).
People with medical illness do not always have an
increased risk of suicidal behaviours. Some studies have
reported that persons with severe physical illness (e.g.,
AIDS) are less suicidal because they are more concerned
about their health and getting better than ending their
own life (Kaplan, McFarland, Huguet, & Newsom, 2007;
Clinical correlates of suicidality among individuals with HIV infection and
AIDS disease in Mbarara, Uganda
Godfrey Zari Rukundo1*, Eugene Kinyanda2 and Brian Mishara3
1Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
2Department of Psychiatry, Makerere College of Health Sciences, and Medical Research Council, Entebbe, Uganda
3Centre for Research and Intervention on Suicide and Euthanasia and Psychology Department, Université du Québec,Montreal,
Canada
*Corresponding author email: grukundo@must.ac.ug
The association between suicidality and HIV/AIDS has been demonstrated for three decades, but little is know about
risk factors that can help understand this association and help identify who is most at risk. Few research studies
have been conducted in sub-Saharan Africa, a region that accounts for more than 70% of the HIV global burden.
This paper describes clinical risk factors for suicidality among individuals with HIV infection and AIDS disease in
Mbarara, Uganda. In this study, suicidality includes both suicidal ideation and suicidal attempts. A cross-sectional
survey was conducted with 543 HIV-positive individuals aged 15 years and above, recruited from 2 HIV specialised
clinics in Mbarara. Using logistic regression analysis, factors significantly associated with suicidality at 95%
confidence interval were identified. The rate of suicidality was 10% (n = 54; 95% CI: 5.00–15.00). Risk factors for
suicidality were: perception of poor physical health (OR 2.22, 95% CI 1.23–3.99, p = 0.007), physical pain (OR 1.83,
95% CI 1.01–3.30, p = 0.049), reducing work due to illness (OR = 2.22, 95% CI 1.23–3.99, p = 0.004) and recent HIV
diagnosis (OR 1.02, 95% CI 1.01–1.03, p = 0.001). These findings suggest that HIV/AIDS in south-western Uganda is
associated with a considerable burden of suicidality. HIV is associated with several clinical factors that increase
vulnerability to suicidality. There is need for more appropriate interventions targeting these clinical risk factors,
systematic suicide risk assessment and management of suicidal ideation and behaviours in HIV care.
Keywords: physical illness, risk factors, suicide, suicidal attempt, suicidal ideation, prevention
Rukundo, Kinyanda and Mishara228
McKegney & O’Dowd, 1992). This study investigated the
clinical factors with suicidality among HIV-positive persons
attending two HIV clinics in Mbarara municipality, south-
western Uganda. In this study, we use the term, “suicidality”
to combine suicidal ideation and suicidal attempts.
Methods
Study design and location
This was a descriptive cross-sectional study conducted
at the Immune Suppression Syndrome (ISS) clinic of
Mbarara Regional Referral Hospital (MRRH) and The AIDS
Support Organization (TASO) Mbarara branch clinic using
quantitative methods. Both clinics receive and provide
care to HIV-positive patients and are located in Mbarara
municipality south-western Uganda. The ISS clinic is
part of Mbarara regional referral hospital and TASO is a
non-governmental organisation in Uganda that pioneered
care for patients with HIV/AIDS in 1987.
Participants
The participants were individuals living with HIV, registered
and attending either of the clinics.
Inclusion and exclusion criteria
Before being included in the study, the participants had to
meet the following criteria:
• Age of 15 years or more
• Signed informed consent, and assent for people younger
than 18 years
• Being strong enough to provide information
• Registered and receiving care from either ISS or TASO
clinic in Mbarara.
Study tools
Screening for suicidality was conducted using five
questions about death and suicidality, four of which were
used in the study on suicide attempts in the Epidemiologic
Catchment Area Study by Moscicki et al. (1988) in the
United States. The five questions have previously been
used in Uganda by Kinyanda et al. (2012). The questions
were: (1) Have you thought a lot about death in the past?
(2) Have you felt like you wanted to die in the past?
(3) Have you felt so low, and thought about committing
suicide in the past year? (4) Did you attempt suicide in the
past year? (5) Have you ever attempted suicide at some
other time in life? A participant who answered yes to any
of the questions 3–5, was considered to be suicidal. The
World Health Organization (WHO) clinical staging and
CD4 counts were used to determine the stage of HIV
infection at the time of the study (stages I, II, III and IV).
Apart from knowing the clinical stage of HIV, association
between suicidality and the following clinical factors
were assessed: generalised lymphadenopathy, herpes
zoster, oral ulcerations, weight loss of not more than
10%, recurrent upper respiratory tract infections (URTIs),
chronic diarrhoea for more than a month, fevers for more
than a month, oral thrush, Kaposi sarcoma, HIV related
tumours cryptococcal meningitis, chronic cough not due
to TB, physical pain and reduction in performance due to
the illness.
Data collection and analysis
Participants were recruited on clinic days by the first
author and research assistants. Data were collected using
a semi-structured questionnaire that was interviewer
administered for consistency, since some of the participants
could not read and write. All questionnaires were translated
into the locally spoken language (Runyankore-Rukiga).
Data obtained from the respondents were recorded on the
questionnaires and thereafter entered into the computer
using SPSS version 16. A derived variable of suicidality
was obtained by adding the people with suicidal ideation
and attempts. The rate of suicidality was then calculated
dividing the number of suicidal patients by the total number
of study participants. Analysis of data involved generation
of frequencies and means, bi-variate and logistic regression.
Tests for significance were carried out using chi-square for
categorical variables. Results were considered statistically
significant if the p-value was ≤0.05 at 95% confidence
interval. To determine the independent effects of each of
the investigated clinical factors, logistic regression analysis
was undertaken. In the final logistic regression model, only
factors that were statistically significant in bivariate analyses
were included.
Ethical considerations
The study was reviewed and approved by the Institutional
Research and Ethics Committee (MUST-REC) of Mbarara
University of Science and Technology and the leadership
at the two study centres. Written informed consent was
obtained from each adult participant. Participants below 18
years were contacted to give assent and then the primary
caregivers provided written informed consent. The consent
form was in both English and the local language. Participants
signed the consent form after accepting that they themselves
or their children could participate in the study. Participants
who were too unwell (physically or mentally) to consent or
provide information were not interviewed. There were no
prior arrangements for a surrogate consent procedure for
such individuals. Confidentiality was observed by having the
interview in private and not having participant identifiers on
the questionnaires and data sets. All participants found to
have psychiatric illness or increased risk of suicidality were
referred to the mental health unit of Mbarara Hospital for
appropriate treatment. This was done in collaboration with
the case managers at the two clinics.
Results
A total of 573 HIV-positive individuals were contacted and
requested to participate in the study. Of the 573 persons
contacted, 543 agreed to participate in this study assessing
the association between clinical factors in HIV/AIDS and
suicidality. Five percent (n = 30) of the patients refused
to participate in the study for various reasons. The most
common reason for non-participation was coming from too
far away, that their employers had given them limited time
for the clinic visit, the participants associating the study with
the stigma of mental illness.
Forty-four percent (n = 239) of the participants attended the
TASO clinic while 56% (n = 304) attended the ISS clinic (Table
1). Overall, 24% (n = 131) were males and 76% (n = 412) were
African Journal of AIDS Research 2016, 15(3): 227–232 229
females. Their ages ranged from 15 to 70 years with a median
of 36.0 years and a mean age of 36.7 years (SD = 9.7). The
mean age of the males was significantly higher than that of the
females (mean age of males = 39.4 years, SD = 10.6; mean
age of females = 35.8 years, SD = 9.1; t = 3.462, p = 0.001).
Most (n = 284; 52%) participants had attained only primary
level education, 20% (n = 107) had no formal education,
22.7% (n = 123) had secondary school education and only
6% (n = 32) had post secondary or vocational training. More
females (76%) than males (60%) were likely to have no formal
education or only a primary level education (OR 1.65; 95 % CI:
1.26–2.15; p = 0.001).
Fifty-six percent of the females (n = 231) were widowed,
separated or divorced compared to 19% of the males
(OR = 5.47, 95% CI 3.39–8.81 p = 0.001). There was a
statistically significant difference between males and females
on employment status (OR = 1.81, 95% CI 1.22–2.69
p = 0.003), with the majority (60%) of the females being in the
categories of peasants or the unemployed while most males
(55%) were in formal employment or full-time business.
Prevalence of suicidality in HIV/AIDS
Suicidal ideation in the preceding year was reported by 8.8%
(n = 48; 95% CI: 6.70–11.50) of participants, and 3.1% (17,
95% CI 2.00–5.00) had attempted suicide in the same year
and 3% (n = 16) had attempted suicide at some other time in
their life. In total, 10% of the study participants (n = 54; 95%
CI: 5.00–15.00) met the criteria for suicidality as defined
in this study (either had suicidal ideation in the last year or
attempted suicide in one’s life time). Of those with suicidal
ideation in the previous year, one-third of them (33%) had
also attempted suicide.
Clinical factors and suicidality in HIV/AIDS
Seventy-six per cent (n = 413) of the participants had
reported excellent or good physical health in the past 3
months and 8% (n = 45) had to cut down on activities
because of physical illness. There was no significant
difference between the two sites in terms of clinical
conditions associated with HIV/AIDS. According to the
WHO clinical staging of HIV, 83% (n = 452) were in stages
I and II, 13% (n = 70) were in stage III and 4% (n = 21) in
stage IV. According to the participants most recent CD4 cell
counts, 16% (n = 89) had 0–200 cells/µL, 45% (n = 244) had
201–500 cells/µL, 23% (n = 127) had ≥ 501 cells/µL, while
15% (n = 83) had never had their CD4 counts done. Seventy
percent (n = 382) were on antiretrovirals (ARVs) and 30%
(n = 161) were ARV naïve.
Relationship between clinical factors and suicidality in
HIV/AIDS
Of the clinical factors assessed at bivariate analysis (Table
2), the following were significantly associated with suicidality:
perception of poor physical health (OR 2.22, 95% CI
1.23–3.99, p = 0.007), physical pain (OR 1.83, 95% CI
1.01–3.30, p = 0.049), decreasing their work due to illness
(OR = 2.22, 95% CI 1.23–3.99, p = 0.004) and duration of HIV
infection (those newly infected having higher proportions with
suicidality than those who had lived longer with the infection)
(OR 1.02, 95% CI 1.01–1.03, p = 0.001). The clinical factors
not significantly associated with suicidality were: symptoms
of diarrhoea, weight loss, Kaposi sarcoma, unexplained
fevers, oral thrush, herpes zoster, memory problems,
lymphadenopathy, chronic cough and skin rash. Other clinical
factors not associated with suicidality in this study were being
on ARVs, HIV stage and CD4 cell count. Clinical factors
that were significantly associated with suicidality at bivariate
analysis were included in the model for the subsequent
analysis. In the final logistic regression analysis, none of the
clinical factors remained statistically significant.
Discussion
The goal of this study was to investigate HIV/AIDS related
clinical factors associated with suicidality among HIV-
positive persons attending two HIV clinics in Mbarara
Table 1: Demographic characteristics by gender July–October
2009 (N = 543)
Variable Female
n (%)
Male
n (%) Total N (%)
District
Mbarara 256 (62.1) 76 (58.8) 332 (61.1)
Isingiro 77 (18.7) 27 (20.6) 104 (19.2)
Bushenyi 32 (7.7) 13 (9.9) 45 (8.3)
Ntungamo 19 (4.6) 1 (0.8) 20 (3.7)
Other 28 (6.8) 14 (10.1) 42 (7.7)
Study site
ISS Clinic 231 (56.1) 73 (55.7) 304 (56.0)
TASO Clinic 181 (43.9) 58 (44.3) 239 (44.0)
Age
Adolescents (15–19) 11 (2.7) 3 (2.3) 14 (2.6)
Young adults (20–34) 178 (43.2) 40 (30.5) 218 (40.1)
Middle age (35–59) 216 (52.4) 83 (61.1) 299 (55.1)
Elderly (60+) 7 (1.7) 5 (6.1) 12 (2.2)
Tribe
Munyankore 322 (78.2) 101 (77.1) 423 (77.9)
Mukiga 38 (9.2) 13 (9.9) 51 (9.4)
Muganda 28 (6.8) 5 (3.8) 33 (6.1)
Other 24 (5.8) 12 (9.2) 36 (6.6)
Religion
Anglican 202 (49.0) 71 (58.8) 273 (50.3)
Catholic 132 (32.0) 43 (32.8) 175 (32.2)
Saved 37 (9.0) 8 (6.1) 45 (8.3)
Moslem 37 (9.0) 8 (6.1) 45 (8.3)
Other 4 (1.0) 1 (0.8) 5 (0.9)
Marital status
Never married 41 (10.0) 22 (16.8) 63 (11.6)
Married/cohabiting 139 (33.7) 84 (64.1) 223 (41.1)
Widowed/separated/
divorced
232 (56.3) 25 (19.1) 257 (47.3)
Level of education
Primary or no formal
education
310 (75.2) 78 (59.5) 388 (71.5)
Secondary or higher
education
101 (24.8) 53 (40.5) 154 (28.5)
Employment
Formal employment 124 (30.1) 45 (34.4) 169 (31.1)
Peasant 207 (50.2) 53 (40.5) 260 (47.9)
Home maker 13 (3.2) 1 (0.8) 14 (2.6)
Other jobs 29 (7.0) 26 (19.9) 55 (10.1)
Unemployed 38 (9.2) 5 (3.8) 43 (7.9)
Total 412 (100) 131 (100) 543 (100)
Rukundo, Kinyanda and Mishara230
municipality, south-western Uganda. The prevalence of
suicidality was found to be 10% of the study population. This
may be considered as a fairly high rate whose importance
is due to the increased risk of repetition in attempters and
their greater risk of an eventual death by suicide (Ferreira
et al., 2015). Although perceived poor physical health,
physical pain, duration of HIV infection and decreasing work
due to illness were significantly associated with suicidality
in bivariate analysis, none of these factors remained
statistically significant in the final logistic regression. In HIV
infection and AIDS, many factors contribute to the increased
risk for suicidality. There is no single clinical factor or
physical symptom that can by itself significantly increase the
risk of suicidality.
Participants who reported that their physical health
was poor or very poor in the past three months had
higher odds for suicidality. This negative perception
about their physical health could also be associated with
other factors, such as depression, anxiety and other
physical conditions (Qin, Hawton, Mortensen, & Webb,
2014; Rukundo, Mishara, & Kinyanda, 2016; Van Orden
et al., 2015; Waern et al., 2002). Previous studies have
reported higher rates of suicidality in physical illness,
but not necessarily among the severely ill (Kaplan et al.,
2007; Qin et al., 2014). In our study, significant weight
loss, unexplained fevers, Kaposi sarcoma and memory
problems were associated with lower odds for suicidality
in the study population. These clinical features could
easily be associated with other medical conditions that
require attention and care. It is possible that individuals
with these symptoms received care from other people
and they were not stigmatised or abandoned as much
as people with depression who look healthy. In addition,
people who are severely ill may not be strong enough to
execute a suicide plan. However, these findings are not in
agreement with some of the previous studies which have
found a significant association between severe physical
illness and increased risk for suicide (Waern et al., 2002;
Webb et al., 2012). These differences may be due to
differences in the study populations and methodological
differences in how physical illness and suicidality were
measured.
Physical pain was also associated with higher odds for
suicidality. This is consistent with findings in previous studies
which have reported higher suicidality in illnesses associated
with pain and shame (a component of psychological pain).
Pain is associated with hopelessness and increased fear
of the future, which is an indication of increased risk for
suicidality. Previous studies have also associated suicidality
with memory problems. For example, Alfonso and Cohen
(1994) reported that memory problems are associated with
impulsivity, lability of mood and impaired judgment, which in
turn increase the risk for suicidality. We found that although
memory problems and other physical disorders were
associated with suicidality, none of them could independently
predict suicidality (Carrico et al., 2007).
A substantial number of the study participants, 15%
(n = 83) did not know their CD4 count results because they
had either just joined the clinics or were still waiting for the
results to be processed. As a result, these people had not
Table 2: Relationship between clinical factors and suicidality in HIV-infected patients at two HIV clinics in Mbarara district July–October 2009
(N = 543)
Variable Frequency
n (%)
Suicidal
n (%)
Non-suicidal
n (%)
ORs
(95% CI) P-value Adjusted ORs
(95% CI) P-value
Perception of physical health
Good 413 (76.1) 33 (8.0) 380 (92.0) 1 (Reference)
Poor 130 (23.9) 21 (16.2) 109 (83.8) 2.22 (1.23–3.99) 0.007* 1.87 (0.90–3.88) 0.091
Physical pain
Pain absent 404 (74.4) 34 (8.4) 370 (91.6) 1 (Reference)
Pain present 139 (25.6) 20 (14.4) 119 (85.6) 1.83 (1.01–3.30) 0.049* 0.98 (0. 78–1.24) 0.866
Duration of HIV
Up to 1 year 514 (94.7) 44 (9.0) 470 (91.0) 0.21 (0.06–0.71) 0.012 0.42 (0.24–0.73) 0.002*
1 to 5 years 13 (2.4) 4 (31.0) 9 (69.0) 1 (Reference)
More than 5 yers 16 (2.9) 6 (38.0) 10 (62.0) 1.35 (0.29–6.38) 0.705
Weight loss
No weight loss 441 (81.2) 35 (7.9) 406 (92.1) 1 (Reference)
Weight loss present 102 (18.8) 19 (18.6) 83 (81.4) 0.38 (0.21–.69) 0.003* 0.54 (0.28–1.05) 0.071
Fevers
Yes 130 (23.9) 20 (15.4) 110 (84.6) 0.49 (.27–.89) 0.028* 0.66 (0.35–1.24) 0.203
No 413 (76.1) 34 (8.2) 379 (91.8) 1 (Reference)
Memory problems
Yes 80 (14.7) 13 (16.3) 67 (83.7) 0.50 (0.26–0.98) 0.041* 0.67 (0.33–1.37) 0.268
No 463 (85.3) 41 (8.9) 422 (91.1) 1 (Reference)
Kaposi sarcoma
Yes 20 (3.7) 5 (25.0) 15 (75.0) 0.31 (0.11–0.89) 0.022* 0.50 (0.16–1.66) 0.249
No 423 (96.3) 49 (11.6) 474 (88.4) 1 (Reference)
Reduced activity due to illness
Yes 45 (8.3) 10 (22.2) 35 (77.8) 0.34 (0.16–0.73) 0.004* 0.44 (0.19–1.03) 0.059
No 498 (91.7) 44 (8.8) 454 (91.2) 1 (Reference)
*Denotes statistical significance
African Journal of AIDS Research 2016, 15(3): 227–232 231
started taking anti-retroviral therapy. At the time of the study,
the CD4 cell count results would take a long time due to
lack of machines at the facilities. We found no significant
association between CD4 cell count and suicidality.
However, previous studies have reported low CD4 cell count
as a high risk factor for psychiatric disorders and suicidality
(Cooperman & Simoni, 2005). This difference could be
due to other factors, such as the increased social support
provided at the study sites.
Conclusion
HIV/AIDS is still associated with a considerable burden of
suicidality in south-western Uganda. No single clinical factor
could independently predict suicidality in HIV/AIDS. Multiple
factors work together to increase vulnerability to suicidality.
Holistic care that includes suicide risk assessment and
management should be adopted while caring for people
living with HIV/AIDS.
Limitations
This being a cross-sectional study, the nature of the
causal relationships between suicidality and the factors
we investigated could not be determined. Also, individuals
younger than 15 years were excluded from the study to
avoid difficulties of using adult tools which have not been
validated with children. Hence, a significant number
of persons with HIV/AIDS were not included, and we
cannot know if our results would be the same in younger
age groups. Third, the presence of other illnesses, such
as diabetes and hypertension, and their associated
symptoms could confound the associations with HIV/AIDS
which we observed.
Acknowledgements — The authors acknowledge support received
from Faculty of Medicine, Mbarara University of Science and
Technology for data collection as well the Centre for Research and
Intervention on Suicide and Euthanasia (CRISE) at the Université
du Québec à Montréal for data analysis. The authors also
acknowledge the contribution of Dr Adriana Carvalhal and Dr Eric
Wobudeya during the design of the study.
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... Among the 21 studies included in the final analysis, data regarding suicidal attempt was reported in eight studies [8,15,18,24,[28][29][30]. The prevalence of suicidal attempts reported in these included studies ranges from 3.1% in Nigeria [46] to 20.1% in Ethiopia [28]. The pooled prevalence of suicidal attempts in these studies was 11.06% (95% CI 6.21, 15.92). ...
Background:
Suicidal ideation and suicidal attempt are warning signs for and determine the prognosis of completed suicide. These suicidal behaviors are much more pronounced in people living with HIV/AIDS. Despite this, there is a scarcity of aggregate evidence in Africa. This study was therefore aimed to fill this gap.
Methods:
we extensively searched Psych-info, PubMed, Scopus, and EMBASE to obtain eligible studies. Further screening for a reference list of articles was also done. Meta XL package was used to extract data and the Stata-11 was also employed. Cochran's Q- and the Higgs I2 test were engaged to check heterogeneity. Sensitivity and subgroup analysis were implemented. Egger's test and funnel plots were used in detecting publication bias.
Results:
The pooled prevalence of suicidal ideation was 21.7% (95% CI 16.80, 26.63). The pooled prevalence of suicidal ideation in Ethiopia, Nigeria, Uganda, and South Africa was 22.7%, 25.3%, 9.8%, and 18.05% respectively. The pooled prevalence of suicidal ideation was larger; 27.7% in studies that used Composite International Diagnostic Interview (CIDI) than Mini-international Neuropsychiatric Interview (MINI); 16.96%. Moreover, the prevalence of suicidal ideation in studies with a sample size of < 400 was 23.42% whereas it was 18.3% in studies with a sample size ≥ of 400 participants. The pooled prevalence of suicidal attempts in this study was 11.06% (95% CI 6.21, 15.92). A suicidal attempt was higher in Ethiopia (16.97%) and Nigeria (16.20%) than Uganda (3.51%). This pooled prevalence of suicidal attempt was higher among studies that used a smaller sample (< 400 participants) (15.5%) than studies that used a larger sample size (≥ 400 participants) (8.4%). The pooled prevalence of suicidal attempt was 3.75%, and 16.97% in studies that used MINI and CIDI respectively. Our narrative synthesis revealed that advanced stages of AIDS, co-morbid depression, perceived HIV stigma, and poor social support was among the factors strongly associated with suicidal ideation and attempt.
Conclusion:
The pooled magnitude of suicidal ideation and attempt was high and factors like advanced stages of AIDS, co-morbid depression, perceived stigma, and poor social support were related to it. Clinicians should be geared towards this mental health problem of HIV patients during management.
... These variables appear to be similar in both youth and adults [14]. In addition to the psychosocial factors, individuals with HIV also experience challenges with clinical symptoms that subjects them to additional difficulties [15]. The greatest HIV/AIDS burden is born by sub-Saharan Africa (SSA), a region with the youngest populations [16,17]. ...
Background
Research from high income countries indicates that suicide is a major mental health care concern and a leading cause of preventable deaths among children and adolescents. Proper assessment and management of youth suicidality is crucial in suicide prevention, but little is known about its prevalence and associated risk factors in Sub-Saharan Africa. In low income countries there is an increased risk of suicide among persons with HIV/AIDS even in the presence of the highly active antiretroviral therapy.
Objective
To determine the prevalence of and risk factors for youth suicidality among perinatally infected youth living with HIV/AIDS in Uganda.
Methods
We studied 392 HIV positive children (5–11 years) and adolescents (12–17 years) and their caregivers in Kampala and Masaka districts. Caregivers were administered the suicide assessment section of the MINI International Psychiatric Interview. Socio-demographic characteristics, psychiatric diagnoses, and psychosocial and clinical factors were assessed and suicidality (suicidal ideation and or suicidal attempt) was the outcome variable. Logistic regression was used to calculate odds ratios adjusting for study site and sex at 95% confidence intervals.
Results
Caregivers reported a suicidality rate of 10.7% (CI 8–14.1) in the past one month with higher rates among urban female (12.4%, CI 8.6–17.7) than male (8.7%, CI 5.4–13.8) youth. Lifetime prevalence of attempted suicide was 2.3% (n = 9, CI 1.2–4.4) with the highest rates among urban female youth. Among children, caregivers reported a lifetime prevalence of attempted suicide of 1.5%. The self-reported rate of attempted suicide in the past month was 1.8% (n = 7, CI 0.8–3.7) with lifetime prevalence of 2.8% (n = 11, CI 1.6–5.0). The most common methods used during suicide attempts were cutting, taking overdose of HIV medications, use of organophosphates, hanging, stabbing and self-starvation. Clinical correlates of suicidality were low socioeconomic status (OR = 2.27, CI 1.06–4.87, p = 0.04), HIV felt stigma (OR = 2.10, CI 1.04–3.00, p = 0.02), and major depressive disorder (OR = 1.80, CI 0.48–2.10, p = 0.04). Attention-deficit/hyperactivity disorder was protective against suicidality (OR = 0.41, CI 0.18–0.92, p = 0.04).
Conclusion
The one-month prevalence of suicidality among CA-HIV was 10.7%.
... In comparison, a study among HIV patients in Uganda, reported that physical pain was a statistically significant correlate of suicidality (suicidal behaviour) only in the bivariable analysis. 33 The correlation of physical pain and suicidal behaviour may differ by type, intensity, and duration of pain. 34 However, this was beyond the scope of our study. ...
... Adolescents with underlying immunosuppression would be about four times more likely to attempt suicidal acts compared to healthy adolescents [10]. This finding is explained by a lack of psychosocial care for people living with HIV [10,11]. Twenty-four adolescents with suicidal attempts, had a family history of suicides (p = 0.0461), an odds-ratio of 2.04. ...
Objectives
The purpose of this study was to study the epidemiological and clinical profile of adolescents with suicidal thoughts, with or without suicide attempts, and to identify associated factors.
Results
A total of 155 (16.5%) of the 941 adolescents interviewed had suicidal thoughts. The average age of the respondents was 18 ± 2.1 years. The sex ratio (m/f) was 1.4. With regard to marital status, 70.2% were single and 29.8% were in a relationship with a cohabiting partner. Family history of suicide was reported in 40%. In their personal history, eight were infected with HIV, three were chronic ethylic and two were diabetics. Forty-six (29.7%) of the 155 adolescents who had suicidal ideation had ever had a suicide attempt. Teens affected by suicide lived in a boarding school in 25.8%, with one parent in 23.9% and 50.3% with both parents. Factors associated with suicide attempts were female sex (p = 0.0107), age over 18 years (p = 0.0177), living in a couple (p = 0.0316), underlying immunodepression (HIV infection, p = 0.0059, sickle cell disease, p = 0.0043) and having a family history of suicides (p = 0.0461).
... This finding was almost in line with the studies conducted in South Africa among HIV-positive patients at HIV counseling and testing clinic, 17.1% [20], Chelsea among HIV-positive population, 26.9% [21], North America, 26% [22], Duke University, the University of Alabama at Birmingham (UAB), Northern Outreach Clinic (NOC) in Henderson, North Carolina, and the University of North Carolina at Chapel Hill (UNC), 23% [23], as well as HIV-positive individuals in four US cities (San Francisco, Los Angeles, Milwaukee, and New York City), 19% [24]. However, it is higher than that in a study conducted in Mbarara, Uganda, among HIV-positive patients, 10% [25]. This variation may be due to variation in age of the participants. ...
Background . Human Immune Deficiency Virus (HIV/AIDS) continues to be an underrecognized risk for suicidal ideation, suicidal attempt, and completion of suicide. Suicidal ideation and attempt in HIV/AIDS is not only a predictor of future attempted suicide and completed suicide. Methods . An institution based cross-sectional study was conducted among HIV-positive patients attending HIV care at Zewditu Memorial Hospital. Systematic random sampling technique was used to recruit 423 participants from April to May 2014. Composite International Diagnostic Interview was used to collect data. Multivariable logistic regression was computed to assess factors associated with suicidal ideation and attempt. Result . Suicidal ideation and suicidal attempt were found to be 22.5% and 13.9%, respectively. WHO clinical stage of HIV, not being on HAART, depression, family history of suicidal attempt, and perceived stigma were associated with suicidal ideation. WHO clinical stage, being female, not being on HAART, use of substance, and depression were associated with suicidal attempt. Conclusion . Early diagnosis and treatment of opportunistic infections, depression, and early initiation of ART need to be encouraged in HIV-positive adults. Furthermore, counseling on substance use and its consequences and early identification of HIV-positive people with family history of suicidal ideation have to be considered.
HIV remains an independent risk factor for suicide even decades after major developments in antiretroviral therapy transformed the illness from acute and fatal to chronic and manageable for many patients. Risk for suicide in people living with HIV is not uniform and can vary considerably based on factors including the phase of the illness, access to treatment, multi-morbidities, and the degree of perceived stigma or social support available. In this chapter we will present an overview of the epidemiology of suicide of HIV-infected persons on all continents. The epidemiology of suicide in persons with HIV is complicated by the fact that suicides may be deliberately or unintentionally misclassified as accidents or drug overdoses. We review the predisposing factors for suicide using a biopsychosocial perspective. It is important to identify the most significant and clinically relevant predisposing factors clinically in a timely manner. We present the protective factors that allow individuals to adapt to affect-laden and disabling medical and psychosocial demands. Many protective factors involve psychological and sociocultural traits and skills and correlate with resilience, improved quality of life, and survival. We describe the pertinent psychodynamic aspects of suicide in persons with HIV within a sociological contextual framework. Three case vignettes will be used to further illustrate these concepts. In this chapter we address assessment and prevention strategies of therapeutic value for suicidal persons with HIV and AIDS.
Objectives:
Attributions for attempting suicide were explored in older adults with and without serious physical illness.
Methods:
An open-ended question was used to explore attributions for attempting suicide in 101 hospitalized persons aged 70+. Serious physical illness was defined as a score of 3 or 4 on any of the 13 non-psychiatric organ categories in the Cumulative Illness Rating Scale for Geriatrics.
Results:
Roughly one-third of hospitalized persons with (22/62) and without (12/39) serious physical illness attributed the suicide attempt to somatic distress. Among 70- to 79-year-olds, seriously physically ill patients were more likely than healthier patients to attribute their attempt to psychological pain (84% vs. 48%, p = 0.013). There were no significant differences in attributions in persons with and without serious health problems in the 80+ group.
Conclusions:
The processes by which physical illness confers risk for attempted suicide in older adulthood may be age dependent. Interventions are needed to mitigate psychological pain in physically ill older patients, especially those in their seventies. Research is needed to understand how the psychological processes that influence the desire for suicide change across older adulthood. Copyright © 2015 John Wiley & Sons, Ltd.
Objectives:
To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older.
Method:
Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review.
Results:
Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed.
Conclusion:
Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.
Characterize admissions to an emergency hospital due to suicide attempts and verify outcomes in two years.
Data were collected from medical records and were analyzed using descriptive statistics and logistic regression.
The sample consisted of 412 patients (58.7% women; mean age = 32.6 years old, SD = 14.3). Self-poisoning was the most frequent method (84.0%), and they were diagnosed mainly as depressive (40.3%) and borderline personality disorders (19.1%). Previous suicide attempts and current psychiatric treatment were reported by, respectively, 32.0% and 28.4%. Fifteen patients (3.6%, 9 males) died during hospitalization. At discharge, 79.3% were referred to community-based psychiatric services. Being male (OR = 2.11; 95% CI = 1.25-3.55), using violent methods (i.e., hanging, firearms and knives) (OR = 1.96; 95% CI = 1.02-3.75) and psychiatric treatment history (OR = 2.58; 95% CI = 1.53-4.36) were predictors for psychiatric hospitalization. Of 258 patients followed for 2 years, 10 (3.9%) died (3 suicide), and 24 (9.3%) undertook new suicide attempts. Patients with a history of psychiatric treatment had higher risks of new suicide attempts (OR = 2.46, 95% CI = 1.07-5.65).
Suicide attempters admitted to emergency hospitals exhibit severe psychiatric disorders, and despite interventions, they continue to present high risks for suicide attempts and death.
Introduction
The proportion of people living with HIV (PLH) in care and on antiretroviral therapy (ART) in Russia is lower than in Sub-Saharan Africa [1]. This is undoubtedly due to a variety of systems and structural issues related to poor treatment access, linkage and care delivery models. However, little research has explored the reasons that PLH are not in care from their own perspectives. This information can help to guide the development of approaches for improving HIV care engagement in the country.
Materials and Methods
In-depth interviews were undertaken with 80 PLH in St. Petersburg who had never been in HIV medical care, had previously been out of care, or had always been in care. Participants were recruited through online PLH forums and Websites, outreach needle exchange and non-government organisation (NGO) programs, and chain referral. The interviews elicited detailed information about participants’ experiences and circumstances responsible for being out of care, and factors contributing to nonretention in HIV treatment. Verbatim transcriptions of the interviews were coded and analyzed using MAXQDA software to identify emerging themes.
Results
Two types of care engagement barriers most often emerged. Some related to medical services, and others to the family and social environment. The most frequent medical service barriers were poor treatment infrastructure conditions and access; dissatisfaction with quality of services and medical staff; and concerns over confidentiality and HIV status disclosure. Social barriers were fears of potential harm to family relationships, negative consequences if status became known at work, and public stigmatization and myths associated having an HIV+ status. Social support from the PLH community and from family and close friends facilitated care engagement, as did motivation to take care of oneself and one's family. Most participants also described circumstances in which engaging into HIV care was brought about by an urgent issue (opportunistic infections) or was enforced through hospitalization or imprisonment. Trust in one's doctor and simply not wanting to die were also common motives.
Conclusions
Stigma was a major barrier to care engagement, including fear that others would learn of one's HIV+ status, whether at work, in one's family, or in the general community. By contrast, support from family, friends and the PLH community contributed to care engagement.
Abstract While global scale-up of prevention of mother-to-child transmission of HIV (PMTCT) services has been expansive, only half of HIV-infected pregnant women receive antiretroviral regimens for PMTCT in sub-Saharan Africa. To evaluate social factors influencing uptake of PMTCT in rural Kenya, we conducted a community-based, cross-sectional survey of mothers residing in the KEMRI/CDC Health and Demographic Surveillance System (HDSS) area. Factors included referrals and acceptability, HIV-related stigma, observed discrimination, and knowledge of violence. Chi-squared tests and multivariate regression analyses were used to detect stigma domains associated with uptake of PMTCT services. Most HIV-positive women (89%) reported blame or judgment of people with HIV, and 46% reported they would feel shame if they were associated with someone with HIV. In multivariate analyses, shame was significantly associated with decreased likelihood of maternal HIV testing (Prevalence Ratio 0.91, 95% Confidence Interval 0.84-0.99), a complete course of maternal antiretrovirals (ARVs) (PR 0.73, 95% CI 0.55-0.97), and infant HIV testing (PR 0.86, 95% CI 0.75-0.99). Community perceptions of why women may be unwilling to take ARVs included stigma, guilt, lack of knowledge, denial, stress, and despair or futility. Interventions that seek to decrease maternal depression and internalization of stigma may facilitate uptake of PMTCT.
OBJECTIVE: To estimate the proportion of inpatients at a university general hospital who are at risk of committing suicide. METHOD: A random sample of 253 patients (57% males) aged 18 years old or older, admitted to surgical and clinical wards, was assessed using the the Mini International Neuropsychiatric Interview, which has a section that evaluates the risk for suicide. Uni- and multivariate analyses were performed. RESULTS: There were 58 (23%) patients with a risk for suicide, 13 (5% of total) of whom presented a high risk. The prevalence of suicide risk was greater in young adult patients, those with no matrimonial relationship and those diagnosed with major depression (univariate analysis, Chi-squared test; p = 0.01, 0.03 and 0.0001, respectively). The multivariate analysis revealed that the risk for suicide in individuals younger than 30 years old was two fold higher than in those individuals between the ages of 30 and 59 years (OR = 0.45, 95% CI = 0.22-0.93; p = 0.03) and four fold greater than in those who were 60 years old or older (OR = 0.25, 95% CI = 0.1-0.64; p = 0.004). CONCLUSION: When young adults are admitted to general hospitals they should receive special attention due to their suicidal potential.
There is a paucity of data on the prevalence of suicidality in HIV/AIDS, and associated psychological factors in sub-Saharan Africa, shown to be high in Uganda. Yet, the region accounts for over 70% of the world HIV burden. Our study used a cross-sectional survey of 226 HIV-positive (HIV+) adults and adolescents (aged 15–17 years) in Mbarara, Uganda. The relationship between suicidality and depressed mood, anxiety symptoms, state anger, self-esteem, trait anger and hopelessness was examined; anger was the predominant factor in suicidality, suggesting that anger management could potentially lower the prevalence of suicidality.
The objective of the study was to examine the association between 39 physical diseases and death by suicide in older adults.
Individual-level register data on all older adults aged 65 years and over living in Denmark during 1990-2009 (N = 1,849,110) were analysed. Rate ratios were calculated for 39 physical diseases while adjusting for period, age group, conjugal status, income, physical comorbidity, and psychiatric disorders.
In all, 4792 older adults aged 65+ died by suicide during the follow-up of >16 million person-years. Gastrointestinal cancer was linked to a rate ratio of 2.5 (95 % CI 1.9-3.5) in men while excess suicide risk for women with brain cancer was 3.5 (95 % CI 1.1-10.8) within three years of diagnosis. Men and women diagnosed with liver diseases within three years experienced a 2.7- (95 % CI 1.7-4.2) and 4.0- (95 % CI 2.5-6.4) fold higher risk of suicide, respectively, than those not diagnosed. Elevated risks of suicide were identified for lung cancer, gastrointestinal cancer, breast cancer, genital cancer, bladder cancer, lymph node cancer, epilepsy, cerebrovascular diseases, cataract, heart diseases, chronic obstructive pulmonary disorders (COPD), gastrointestinal disease, liver disease, arthritis, osteoporosis, prostate disorders, male genital disorders, and spinal fracture when compared to persons not diagnosed within three years.
Multiple physical diseases were linked to increased risks of suicide in older adults. Increased attention to suicidal ideation and risk assessment might be warranted during the diagnosis and treatment of these disorders.
There is paucity of data on the burden of suicidality in HIV/AIDS and associated clinical factors in sub-Saharan Africa. Yet, the region accounts for 70% of the HIV burden. This study aimed to assess the rate and clinical risk factors for suicidality in HIV-positive individuals in semi-urban Uganda. It was a cross-sectional survey of 543 HIV-positive individuals aged 15 years and above recruited from two HIV specialized clinics in Mbarara. Using logistic regression analysis, factors significantly associated with suicidality at 95% confidence interval and p-value of ≤ 0.05 were identified. The rate of suicidality was 10% (n= 54; 95% CI: 5.00-15.00); suicidal ideation 8.8% (n=48; 95% CI: 6.70-11.50) and suicidal attempt 3.1% (17, 95% CI 2.00-5.00). Risk factors for suicidality were: perception of poor physical health (OR 2.22, 95%CI 1.23-3.99, p= 0.007), physical pain (OR 1.83, 95%CI 1.01-3.30, p= .049), reducing on the work due to illness (OR = 2.22, 95%CI 1.23-3.99, p= 0.004) and recent HIV diagnosis (OR 1.02, 95% CI 1.01-1.03, p= 0.001). The findings suggest that HIV/AIDS in south-western Uganda is associated with a considerable burden of suicidality. HIV seems to work secondarily through clinical factors to increase vulnerability to suicidality. Suicide risk assessment and management should be an integral part of HIV care.
HIV is a significant social, political and economic problem in Zimbabwe. However, few researchers have explored peoples' experiences of living with HIV in that country. Drawing on 60 qualitative interviews conducted with Zimbabweans living in Harare in 2010, this paper focuses on how people from four different urban communities cope with HIV-related social stigma. To provide theoretical context to this issue, we utilised the ideas of Erving Goffman for exploring the individual experience of stigma and the concept of structural violence to understand stigma as a social phenomenon. This paper considers the relevance and role of stigma in the context of a country undergoing significant social, political and economic crisis. We investigated the strategies adopted by the Zimbabwean state and the influence of traditional and religious interpretations to appreciate the historical roots of HIV-related stigma. We took into account the ways in which the articulation of HIV with gender has caused women to experience stigma differently than men, and more intensely, and how grassroots activism and biomedical technologies have transformed the experience of stigma.