Psychiatric morbidity among human immunodeficiency virus test seekers attending the integrated counseling and testing center facility of a tertiary care hospital in South India.

Background: Testing for human immunodeficiency virus (HIV) infection has become a mandatory and routine regimen for various reasons. Literature suggests that the level of psychiatric morbidity is high among HIV-infected individuals. However, often psychiatric problems are undetected and untreated among these people and this is possible by the simple measure of screening when these people contact a health-care facility such as an integrated counseling and testing center (ICTC). The paucity of published data in this arena necessitates exploring the facts related to this issue. Hence, this study was aimed to identify the psychiatric morbidity among people undergoing HIV testing by a screening method.
Methods: A cross-sectional, descriptive study was carried out among 384 individuals, those who were undergoing HIV testing at an ICTC facility of a tertiary care hospital in South India. They were assessed for psychiatric morbidity by a structured clinical diagnostic interview using mini international neuropsychiatric interview. Those people who were identified as having psychiatric problem were referred to psychiatric clinic for further management.
Results: The mean age of the patients was 40 (±13.27) years and the males (n = 254, 66.1%) predominated than the females (n = 130, 33.9%). Psychiatric illness was identified in many patients (n = 91, 24%) including major depressive disorder (n = 64, 16.7%), suicidal ideas (n = 31, 8%), panic disorder (n = 26, 6.8%), and substance abuse (n = 15, 3.9%).
Conclusion: The findings imply the need to integrate screening and referral services for the people undergoing HIV testing. Early screening of psychiatric morbidity among individuals utilizing the ICTC facility may help identify and treat the illness at an early stage. Copyright:

Testing for human immunodeficiency virus (HIV) infection has become a mandatory and routine regimen for many patients attending the general health care services, especially, patients attending the clinical departments such as dermatology, tuberculosis clinic, sexually transmitted diseases clinic, and patients undergoing invasive procedures. A population-based cohort study conducted in Taiwan showed high morbidity (23.8%) of psychiatric disorders among HIV-infected individuals.[1] A couple of studies had investigated the psychological distress, depression, and anxiety symptoms among persons undergoing HIV testing. Both the studies found more number of patients with depressive symptoms and clinically significant distress.[23] Another study by Myer et al. from South Africa also demonstrated high levels of depression, posttraumatic stress disorder (PTSD), and alcohol dependence/abuse among HIV-infected individuals.[4]

Globally, 450 million people suffer from a mental or behavioral disturbance and one in four families has at least one person with a mental disorder.[5] Earlier studies have demonstrated that certain psychiatric illnesses such as substance abuse can be a risk factor for HIV infection and increase the rate of vulnerability to HIV infection.[67]

Besides, mental health problems negatively influence and affect HIV treatment access and adherence. Hence, it is essential to explore mental health issues among HIV-infected individuals and the people who are at risk of acquiring HIV infection. Screening is an effective strategy to identify the people with psychiatric illness that would otherwise go undetected or untreated. In developing countries like India where mental health resources are scarce and the services are limited, many people do not have access to these services and the stigma associated with mental illness makes it difficult to recognize and treat the illness at an early stage. Hence, it is necessary to integrate screening and referral services for mental health problems into general health care to enhance the effectiveness of treatment strategies. Very few studies have been conducted in this arena and there is a paucity of data exists regarding this issue. The objective of the study was to identify the psychiatric morbidity among individuals those who attend an integrated counseling and testing center (ICTC) facility of a tertiary care institute undergoing HIV test. A gold standard screening tool, mini international neuropsychiatric interview (MINI) was administered to achieve the objective of the study and the association between demographic variables and psychiatric morbidity was also carried out.

METHODS

A cross-sectional, descriptive study was conducted among individuals (n = 384) those who were undergoing HIV testing at the ICTC facility of a tertiary care hospital in South India. Patients of either sex, aged between 18 and 65 years, were enrolled in the study using purposive sampling technique and those who had already diagnosed with some psychiatric illness were excluded from the study.

The sample size was determined using the formula for estimating a single proportion. The expected proportion of patients attending ICTC having psychiatric morbidity was kept approximately 50% and the sample size was estimated at a 5% level of significance and 5% absolute precision. The sample size required for the study was calculated to be 384 and the same number of samples was included as study patients.

The patients were assessed for psychiatric morbidity by a structured clinical diagnostic interview using MINI. A semi-structured proforma was used to collect the sociodemographic variables. The study was approved by the institute ethics committee.

Patients with HIV test requisition were identified and contacted at the registration counter of ICTC facility and they were informed about the purpose of the study. Those who agreed voluntarily and willingly were enrolled in the study. After being explained the study details, written informed consent was signed by them. Privacy was assured and confidentiality was ensured throughout data collection. They were interviewed in the counseling room attached with ICTC.

The MINI[89] is a structured interview to diagnose psychiatric disorders according to the International Classification Disorders-10th version and Diagnostic and Statistical Manual-fourth version. In this study, the current version of MINI 7.0 was used. This tool has been divided into 16 modules identified by the letters A-P, each corresponding to a diagnostic category. At the beginning of each diagnostic module, screening questions that correspond to the main criteria of the disorder were asked. The remaining questions of each diagnostic module were asked based on the positivity of the screener questions. If the screener was negative, the researcher moved to the subsequent module for further interviewing. Only symptoms occurring during the time frame indicated were considered in the scoring of the responses. The rating for each question was done at the right-hand side of each question by entering the codes as Yes or No.

The following modules of MINI were administered to the patients to determine psychiatric morbidity (major depressive disorder [MDD], generalized anxiety disorder, PTSD, and alcohol use disorder, etc.,). Initially, the investigator was trained by a faculty from the Department of Psychiatry in the administration of MINI. Those patients who were identified with clinically significant psychological distress or a mental disorder were referred to the Psychiatric Department for further management.

The data were analyzed using IBM SPSS version 19.0 (Armonk, NY: IBM Corp.). The psychiatric morbidity was estimated using a confidence interval of 95%. The results were calculated as frequencies, means, and standard deviations. The Chi-square test was used to compare the psychiatric morbidity with sociodemographic variables.

RESULTS

A total of 384 patients participated in the study. Predominantly, males (n = 254, 66.1%) were present than females (n = 130, 33.9%). The mean age of the patients was 40 (±13.27) years. Socio-demographic profile of the patients is illustrated in Table 1. Majority were married (n = 287, 74.7%); 246 (64.1%) had formal education; 275 (71.6%) patients were employed; 371 (96.6%) patients had no family history of any psychiatric disorders; and 202 (52.6%) had the income of <3000 rupees.

Table 1

Sociodemographic characteristics of study participants (n=384)

Variables	Categories	Frequency, n (%)
Gender	Male	254 (66.1)
	Female	130 (33.9)
Marital status	Single	89 (23.2)
	Married	287 (74.7)
	Divorced	1 (0.3)
	Widowed	7 (1.8)
Education status	Formal education	246 (64.1)
	Nonformal education	138 (35.9)
Employed status	Employed	275 (71.6)
	Un-employed	109 (28.4)
Occupation	Skilled	114 (29.7)
	Unskilled	235 (61.2)
	Student	35 (9.1)
Income	<3000	202 (52.6)
	>3000	182 (47.4)
Family history of psychiatric illness	Yes	13 (3.4)
	No	371 (96.6)

Psychiatric morbidity was present in 91 (24%) patients. The prevalence estimate of various mental disorders that was screened and identified by MINI is listed in Table 2. MDD was present in 64 (16.4%) patients; suicidal ideations in 31 (8%), panic disorder in 26 (6.8%), alcohol use disorder in 15 (3.9%), PTSD in 12 (3%), generalized anxiety disorder (0.3%), and organic disorder (1%). Further, 62 (68%) patients were diagnosed with at least one psychiatric disorder and the rest were diagnosed with two psychiatric disorders (n = 29, 38%) such as depression with suicidality or ADS with depression.

Table 2

Psychiatric morbidity estimates of various mental disorders

Various mental disorders	Frequency, n (%)
Major depressive disorder	64 (16.67)
Suicidality	31 (8.0)
Manic episode	2 (0.5)
Panic disorder	26 (6.8)
Social anxiety disorder	7 (1.8)
OCD	1 (0.3)
PTSD	12 (3.0)
ADS	15 (3.9)
Generalized anxiety disorder	1 (0.3)
Organic disorder	4 (1.0)

OCD – Obsessive-compulsive disorder; PTSD – Posttraumatic stress disorder, ADS – Alcohol use disorder

The Chi-square analysis indicated that there was no significant association between the sociodemographic variables (gender, marital status, education, employed status, occupation, and monthly income) and psychiatric morbidity. The details are illustrated in Table 3.

Table 3

Association of psychiatric morbidity with selected demographic variables (n=384)

Demographic variables	Categories	Psychiatric morbidity
		Present, n (%)	Absent, n (%)	χ 2	P
Gender	Male	58 (22.8)	196 (77.2)	0.30	0.57
	Female	33 (25.4)	97 (74.6)
Marital	Single	19 (21.3)	70 (78.7)	0.75	0.86
	Married	70 (24.4)	217 (75.6)
	Divorced	0	1 (100)
	Widowed	2 (28.6)	5 (71.4)
Education	Formal education	57 (23.2)	189 (76.8)	0.10	0.41
	Nonformal education	34 (24.6)	104 (75.4)
Employed	Yes	67 (24.4)	208 (75.6)	0.23	0.62
	No	24 (22.0)	85 (78.0)
Occupation	Skilled	33 (28.9)	81 (71.1)	4.17	0.09
	Unskilled	54 (23.0)	181 (77.0)
	Student	4 (11.4)	31 (88,6)
Monthly income	<3000	44 (21.8)	158 (78.2)	0.86	0.35
	>3000	47 (25.8)	135 (74.2)
Family history of psychiatric illness	Yes	4 (30.8)	9 (69.2)	0.37	0.54
	No	87 (23.5)	284 (76.5)

DISCUSSION

Many researchers have investigated the prevalence of mental disorders among people infected with HIV.[1011] Literature suggests that the level of anxiety and depression are high in HIV-tested people.[234] Very few studies have investigated the presence of psychiatric morbidity among individuals undergoing HIV test.[23] Individuals undergoing HIV tests are expected to experience significant amount of distress due to the stigma and the fear associated with HIV infection.[10] Mental health disorders, particularly depressive disorders, have been shown to negatively influence HIV test-seeking behavior and adherence to antiretroviral therapy.[12]

Except few studies, the previous studies conducted among HIV test seekers focused only on depression and anxiety. The current study was conducted to screen the major psychiatric illnesses that are screened by MINI.

The mean age of the patients was 40 years which is similar to a study conducted by Kagee et al.(39 years)[11] and by a Kenyan study (37.3 years).[13] The national mental health survey reported that mental health problems were more in people aged between 30 and 49 years.[14]

Database from a nationally representative cohort of newly diagnosed HIV-infected patients from Taiwan reported that 23.8% of patients were identified as having psychiatric disorders.[1] Almost, a similar percentage (24%) of psychiatric morbidity was found among HIV test seekers attending the ICTC facility of our institute. According to the national mental health survey, the prevalence of psychiatric morbidity among the general population was 10.6%.[14] These findings suggest that the psychiatric morbidity is more among HIV-infected people when compared to the general population. Further, a study conducted in North India also reported that the psychiatric morbidity was high in asymptomatic HIV patients when compared to HIV seronegative controls.[15]

A slightly higher percentage (16.4%) of MDD was present in our study when compared to a South African study (MDD was 14.4%) that was done among HIV test seeking individuals, using beck depression inventory (BDI).[16] Whereas BDI is used to screen MDD alone, MINI can be used as a comprehensive tool to assess all major psychiatric illnesses.

In a systematic review by Collins et al., the authors suggested that a process of referral to mental health services must be built into the infrastructure of local and district healthcare centers to address the mental health needs of HIV positive patients. They also insisted that these HIV and mental health service collaborations will be particularly critical for addressing the prevention and treatment needs of people with serious mental illness.[17]

Limitations and strength of study

Nonprobability sampling technique and onetime assessment were done with no follow-up. As the study was conducted in the ICTC of a tertiary care setting, generalization of the results is limited to the population of similar demographical background.

Despite these limitations, our study demonstrates certain specific strengths. First, a gold standard screening tool, the MINI was used in this study which is rarely used in India, in the context of HIV and mental health research. Second, participants were screened for psychiatric morbidity before HIV testing, rather than following the test, which is also unique in terms of the existing body of research.

CONCLUSION

Early screening of psychiatric morbidity among HIV test seekers at the ICTC facility may help identify and treat the illness at an early stage. The integration of mental health care including screening and referral, with HIV testing, will be an appropriate strategy to improve the overall HIV care and management.

Financial support and sponsorship

Intramural fund received from JIPMER.

Conflicts of interest

There are no conflicts of interest.