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Depression and Thoughts of
Suicide Among Middle-Aged and Older Persons Living With HIV-AIDS
Seth C. Kalichman, Ph.D., Timothy Heckman, Ph.D., Arlene Kochman,
M.S.W., Kathleen Sikkema, Ph.D. and Jo Bergholte
http://www.psychservices.psychiatryonline.org/cgi/content/full/51/7/903
Abstract
OBJECTIVE: This study examined the prevalence and
characteristics of suicidal ideation among middle-aged and older
persons who have HIV infection or AIDS. METHODS: A total of 113
subjects older than age 45 who had HIV-AIDS were recruited from
AIDS service organizations in Milwaukee, Wisconsin, and New York
City. Participants completed confidential questionnaires
covering suicidal ideation, emotional distress, quality of life,
coping, and social support. RESULTS: Twenty-seven percent of
respondents reported having thought about taking their own life
in the previous week. Those who had thought about suicide
reported greater levels of emotional distress and poorer
health-related quality of life than those who had not considered
suicide. They were also significantly more likely to use escape
and avoidance strategies for coping with HIV infection and less
likely to use positive-reappraisal coping. Those who had thought
about suicide also were more likely to have disclosed their HIV
status to the people close to them, and yet they perceived
receiving significantly less social support from friends and
family. With the exceptions of physical functioning and coping
strategies, differences between those who had contemplated
suicide and those who had not remained unchanged after
controlling for symptoms of depression. CONCLUSIONS: Persons who
are in midlife and older and are living with HIV-AIDS experience
significant emotional distress and thoughts of suicide,
suggesting a need for targeted interventions to improve mental
health and prevent suicide.
Introduction
Once an epidemic concentrated among the young, AIDS is
increasingly affecting older adults. Of all persons in the
United States who have been diagnosed as having AIDS, the
proportion who were men age 45 and older cumulatively increased
from 9 percent in 1995 to 21 percent in mid-1999. A similar
escalation in AIDS cases was observed in women age 45 and older,
who constituted 6 percent of all cases in 1995 and 16 percent in
mid-1999.
New HIV infection rates also suggest that the trend toward
greater percentages of older adults with an AIDS diagnosis will
continue; 29 percent of men and 24 percent of women newly
infected with HIV in 1997 were between 35 and 44 years old
(1,2). Thus more adults are becoming infected in their thirties
and forties, and advances in treatments for both HIV infection
and AIDS-associated conditions are increasing the longevity of
those living with HIV infection. Although older adults clearly
constitute a growing population of people with HIV-AIDS, little
is known about their mental health needs and their ability to
cope with HIV infection.
Research with younger populations suggests that people who are
HIV positive may be at greater risk for suicide than their
uninfected counterparts (3,4,5,6). In a study of more than 2,300
psychiatric consultations in a New York City hospital,
approximately 20 percent of patients with HIV infection
exhibited suicidal behavior compared with 14 percent of patients
with unknown HIV serostatus (7). Persons with HIV infection who
attempt suicide are likely to abuse drugs, experience social
isolation, and lack social support (8,9). In addition,
HIV-positive men are at greater risk for suicide than women, and
persons with HIV-AIDS who more frequently use avoidance and
denial strategies for coping with HIV-related stress are at
greater risk for suicide (8,10).
Studies also suggest that patients' risk for suicide may be
greater soon after testing positive for HIV than later on, after
some time has passed and they begin to adjust to living with the
infection (11). For example, using the suicide intention item in
the Beck Depression Inventory, Perry and associates (12) found
that 29 percent of persons with HIV infection had thoughts of
suicide the week before testing for HIV antibodies. In the same
cohort, 27 percent had thoughts of suicide one week after
notification of their HIV-positive test result, and 16 percent
had thoughts of suicide two months later. Although thoughts of
suicide may recede as people adjust to their HIV diagnosis,
there may be a resurgence in suicide risk as HIV-related disease
advances, particularly with the development of AIDS-related
symptoms and illnesses (13).
In the general population, suicide rates are highest among
adults who are in midlife and older, and suicide is among the
ten leading causes of death for individuals 45 to 65 years of
age (14,15,16,17). The AIDS mental health literature to date has
largely overlooked suicidal ideation in older adults with
HIV-AIDS.
We investigated the rates of suicidal ideation and suicide
intention among men and women age 45 and older with HIV
infection or AIDS. Using methods for defining suicidal ideation
similar to those used in previous studies (12), we examined the
relationship between suicidal ideation and self-reported
emotional distress, functional well-being, psychological coping
with HIV-AIDS, and social support among our respondents.
On the basis of cognitive theories of suicide that view thoughts
of suicide on a continuum, with thoughts of self-inflicted harm
defined as a low-threshold indicator of suicide risk (18), we
hypothesized that persons who were thinking of suicide would be
experiencing greater emotional distress and poorer
health-related quality of life than persons not currently
thinking of suicide. We also predicted that those who thought
about suicide in the previous week would be more likely to use
avoidance and denial-related coping strategies in dealing with
their HIV infection. Finally, we hypothesized that middle-aged
and older adults with HIV infection who had thoughts of suicide
would be less likely to disclose their HIV status to others,
thereby increasing their social isolation, and would perceive
less social support than those not thinking of suicide.
Methods
Participants
Participants were 85 men and 28 women living with HIV-AIDS who
were recruited from community-based organizations in Milwaukee,
Wisconsin (N=22), and New York City (N=91). Their mean±SD age
was 53.4±.5 years (range, 47 to 69 years), with 66 percent
between the ages of 45 and 54 years. The sample was ethnically
diverse; of the 113 participants, 48 were white (43 percent), 48
were African American (43 percent), nine were Hispanic (8
percent), and eight were of other ethnicities (6 percent). The
mean±SD years of education was 14±2.4, with 32 percent having
completed 12 years or more of schooling. Twenty-six were
currently married or had a partner (23 percent), and 55 had
children (49 percent).
Participants were also diverse in their HIV risk histories.
Sixty-five persons believed that they had become infected
through sexual contact (58 percent), 12 through injection drug
use (11 percent), and three through blood transfusions (3
percent); 33 did not know the source of their HIV infection (29
percent). The median time since testing positive for HIV was
eight years (range, two to 16 years). Forty-one respondents were
not currently experiencing symptoms of HIV infection (36
percent), and 49 had not been diagnosed as having AIDS (43
percent).
Procedures
The study was conducted in 1998 and 1999 in collaboration with
AIDS service organizations in Milwaukee and New York City. Case
managers were asked to contact their clients who were in midlife
or older to inform them of the opportunity to participate in a
mental health and life care needs assessment for people living
with HIV-AIDS. Individuals interested in the study called a
toll-free telephone number and were provided with detailed
information about the study.
Those who wished to enroll in the study were scheduled for an
appointment at the AIDS agency in their city. Participants
provided informed consent at the data collection session and
completed a confidential, self-administered questionnaire. Those
who had reading problems were helped to complete the survey.
Participants were given $20 for completing the survey.
Measures
Demographic and health status. Participants reported their age,
ethnicity, sexual orientation, years of education, the year when
they first tested positive for HIV antibodies, their current
symptoms, if any, of HIV infection, and whether they had been
diagnosed as having an AIDS-defining condition.
Suicidal ideation. We used the suicide intention item from the
Beck Depression Inventory (BDI) to assess suicidal ideation. The
BDI consists of 21 items that reflect cognitive, affective,
behavioral, and somatic symptoms of depression, each scored 0 to
3 according to severity (19,20). We have found that the BDI
provides a valid assessment of depressive symptoms in people
with HIV-AIDS and that depressive and HIV-related symptoms are
easily distinguished because the scale has a somatic symptoms
subscale (21).
The suicidal ideation item presents four statements representing
a continuum of suicide risk: "I don't have any thoughts of
killing myself"; "I have thoughts of killing myself, but I would
not carry them out"; "I would like to kill myself"; and "I would
kill myself if I had the chance." Participants were instructed
to indicate which statement best applied to them over the past
week. We used this item to form two comparison groups: subjects
who had no thoughts of suicide, or those who selected the first
statement, compared with subjects who had thoughts of suicide,
those who selected any of the other three statements. We also
obtained an adjusted depression score on the BDI after removing
the suicide intention item.
Emotional distress. The Symptom Checklist-90 (SCL-90) (22)
served as an independent index of distress with five subscales:
anxiety, somatization, interpersonal sensitivity, hostility, and
depression (alphas ranging from .71 to .88).
Health-related quality of life. We used the 55-item Functional
Assessment of HIV Infection (23) to assess health-related
quality of life of people with HIV infection. This instrument
has subscales for physical well-being, emotional well-being,
functional well-being, and provider relationship (alphas ranging
from .79 to .91).
Coping behaviors. Participants completed the 66-item Ways of
Coping Questionnaire (24) to assess cognitive and behavioral
coping strategies. The survey has subscales for acceptance of
responsibility, confrontive coping, planful problem solving,
escape and avoidance, distancing, seeking social support,
self-control, and positive reappraisal (alphas ranging from .61
to .78). The higher the subscale score, the greater use the
subject made of that coping strategy.
Social support. Respondents also completed the 15-item Provision
of Social Relations Scale (25), which uses six items to assess
perceived social support from family members and nine items to
assess support from friends (alphas over .85). The higher the
scores, the greater the perception subjects had of social
support from those sources.
Disclosure of HIV infection. Participants were asked whether
they had disclosed their HIV-positive status to immediate
family, to extended family, to a partner or spouse, to close
friends, or to casual friends.
Data analyses
Data analyses compared respondents who had thoughts of suicide
in the past week with those who had not thought about suicide.
Independent t tests were used to compare groups on continuous
demographic and health history variables, and contingency table
chi square tests were used for categorical variables.
To test differences between those with suicidal ideation and
those without on the mental health and coping variables, we
conducted multivariate analyses of covariance (MANCOVAs),
controlling for HIV symptom severity ratings. MANCOVAs were
conducted on four sets of dependent variables: emotional
distress measured by the SCL-90, health-related quality of life,
coping behaviors assessed by the Ways of Coping Questionnaire,
and perceived social support. We controlled for HIV symptoms in
these analyses, using the current HIV symptom assessment,
because persons with suicidal thoughts differed in HIV symptoms
experienced, and because HIV symptoms overlap with somatic
symptoms of emotional distress (21). Numbers of participants in
each group varied because of missing values.
We performed a second series of analyses to compare suicidal
ideation groups while controlling for nonoverlapping depression
symptoms. Using a six-item composite from the SCL-90 depression
subscale— items included feeling blue, sleep that is restless or
disturbed, crying easily, poor appetite, feeling no interest in
things, and loss of sexual interest or pleasure— we repeated the
MANCOVAs comparing suicidal ideation groups on the measures for
emotional distress, quality of life, coping, and social support
after controlling for HIV symptoms and symptoms of depression.
The depression composite was reliable (alpha=.81), and was
highly correlated with scores on the BDI (r=.80, p>.001). These
conservative secondary analyses served to test the effects of
suicidal ideation on mental health outcomes independently of
symptoms of depression other than those related to thoughts of
suicide.
Results
Preliminary analyses did not indicate significant differences
between the Milwaukee and the New York City samples. Inspection
of responses to the BDI suicidal ideation item showed that 29 of
the 113 participants (26 percent) had thought about taking their
own lives in the previous week. However, the immediate risk for
suicide in this group was low. Twenty-seven of them selected the
statement indicating that they had thoughts of killing
themselves but would not carry them out, and the other two
selected the statement indicating that they would like to kill
themselves. None selected the statement indicating that they
would commit suicide if they had the chance.
Differences were observed in the demographic and health
characteristics of respondents with suicidal ideation. Men were
more likely than women to have had suicidal thoughts; 26 men, or
31 percent, reported having had thoughts of suicide, compared
with three women, or 11 percent ( 2=4.6, df=1, p>.05). Whites
were more likely than nonwhites to have had such thoughts, with
18 white respondents, or 38 percent, having considered suicide,
compared with 11 members of minority groups, or 17 percent (
2=5.8, df=1, p>.01). Participants who identified themselves as
gay (N=53) were more likely than heterosexual and bisexual
respondents to have had suicidal ideation; 18 gay respondents,
or 36 percent, compared with 11 heterosexual and bisexual
respondents, or 17 percent, had thought of killing themselves (
2=6.4, df=2, p>.05).
However, among respondents who had suicidal ideation, gender,
race, sexual orientation, and health status were not independent
of one another. Suicidal ideation was most common among white
men who identified themselves as gay. In addition, respondents
who had suicidal ideation who were currently experiencing
HIV-related symptoms (N=18, or 36 percent) were more likely than
those who were currently asymptomatic (N=11, or 17 percent) to
have considered suicide in the past week ( 2=3.9, df=1, p>.05).
None of the remaining demographic and health characteristics
differentiated persons who had thought of suicide in the past
week from those who had not.
Emotional distress, quality of life, and suicidal ideation
For descriptive purposes, we adjusted the BDI scores by removing
the suicidal intention item and compared those who had thoughts
of suicide and those who did not. Not surprisingly, respondents
who had thoughts of suicide reported significantly higher levels
of depression than those who did not (mean±SD BDI score, 20.8±
8.2 versus 9.6±6.4; t=7.31, df=103, p>.01). With the suicide
intention item removed from the scale, 68 percent of the
respondents who had thoughts of suicide still exceeded the
clinical cutoff for depression on the BDI (15 and above),
compared with 16 percent of those who did not have thoughts of
suicide ( 2=26.9, df=1, p>.01).
Results of the MANCOVA comparing suicidal ideation groups on the
five SCL-90 subscales, treating HIV-related symptoms as a
covariant, indicated a host of significant differences between
those who had suicidal thoughts and those who did not (F=13.14,
df=6, 88, p>.01). Differences appeared between the two groups on
all five subscales of emotional distress. Those who had suicidal
thoughts reported greater symptoms of anxiety, somatization,
hostility, interpersonal sensitivity, and depression (for all
comparisons, p>.01).
A separate MANCOVA comparing groups on the functional health
scales, again controlling for HIV symptoms, showed differences
between suicidal ideation groups (F= 9.93, df=4, 91, p>.01).
Those who had contemplated suicide reported poorer physical and
emotional well-being as well as a more diminished functional
well-being than those who did not have thoughts of suicide (for
all comparisons, p>.01). The difference between the two groups
on the variable for satisfaction with health care providers was
not significant.
Coping behaviors and suicidal ideation
Results of the MANCOVA comparing the two groups after
controlling for HIV symptoms revealed significant differences
between those who had suicidal thoughts in the past week and
those who did not (F=3.5, df=8, 82, p>.01). Subsequent analyses
showed that persons who had not considered suicide reported
greater use of positive-reappraisal coping strategies than those
who had thoughts of suicide (p>.03). In contrast, those who had
contemplated suicide were significantly more likely to use
escape and avoidance strategies for coping with HIV-AIDS than
those who had not (p>.01). On the remaining coping scales the
two groups did not differ.
Social support and suicidal ideation
Comparisons between the groups showed that respondents who had
thoughts of suicide in the past week were significantly more
likely to have disclosed their HIV status to their close friends
than those who had not considered suicide ( 2=4.9, df=1, p>.05).
This finding was unexpected. Although the differences for
disclosure to persons other than close friends were not
statistically significant, a pattern in the data indicated that
those who had thought about suicide were more likely to have
disclosed their HIV status to family, friends, and partners.
However, results of a MANCOVA comparing those who had and those
had not considered suicide on measures of social support
received from friends and family, controlling for HIV symptoms,
showed significant differences between groups (F=9.1, df=2, 96,
p>.01). Those who had thought about suicide reported receiving
less social support from both friends and family (p>.01 in both
cases). These differences in social support occurred despite the
fact that those who had considered suicide were more likely to
have disclosed their HIV status to others.
Testing for independent effects
We repeated the analyses for differences between the two groups
on measures of emotional distress, health-related quality of
life, coping behaviors, and social support, this time
controlling for both HIV symptoms and nonoverlapping symptoms of
depression. Significant differences between groups were retained
on all of the emotional distress and health-related
quality-of-life scales (for all comparisons, p>.01) except
somatization and physical functioning. After depression was
controlled for, differences in use of coping strategies between
the two groups were not significant, whereas the results for
social support from family and friends remained unchanged.
These findings show that most differences between persons who
have thoughts of suicide and those who do not are independent of
other symptoms of depression, whereas differences in
somatization, coping strategies, and physical functioning can be
accounted for by depression.
Discussion
One in four middle-aged and older persons with HIV infection or
AIDS in our sample reported having had thoughts about suicide in
the previous week. This rate is similar to that observed among
persons who have just learned that they are HIV positive, but
higher than that observed among persons who have had a period of
weeks or months to adjust to their HIV status (11,12).
Reflecting other findings in the literature on HIV and suicide,
our study found that men reported greater rates of suicidal
ideation than women and that suicidal ideation was associated
with HIV-related physical symptoms (8,13). Also consistent with
previous research, our data showed that those who had suicidal
thoughts were more likely to use escape and avoidance strategies
to cope with HIV infection and were less inclined to use
positive-reappraisal coping (8,9,10), although these differences
were accounted for in nonoverlapping symptoms of depression. Our
findings therefore highlight the more general context of
depression associated with HIV-AIDS in older adults, of which
suicidal ideation is but one important facet.
Contrary to our study hypothesis, we found that respondents who
had thought about suicide were more likely than those who had
not to have disclosed their HIV status to their close friends.
Nevertheless, even after controlling for other symptoms of
depression, we found that those who had thought about suicide
perceived receiving less social support from family and friends
than those who had not.
These findings suggest that persons who think about suicide may
be more likely to reach out to friends and perhaps others for
support. Despite such efforts, however, this group perceived
receiving less support from their families and friends. One
possible reason for the discrepancy between disclosure and
perceived social support is the negatively biased perceptions
that depressed individuals ascribe to their social relationships
(19). Moreover, indiscriminately disclosing one's positive HIV
status may be maladaptive and therefore consistent with other
markers of emotional distress.
On the other hand, suicidal risk may be promoted when
disclosures are met with rejection and the stigma of AIDS rather
than support. Another possibility is that some persons with
HIV-AIDS may consider suicide a last-resort option for escaping
terminal illness, in which case thoughts of suicide serve as a
coping mechanism (26). Unfortunately, our cross-sectional study
design precludes any such causal interpretations. Our study
design also does not provide information about premorbid
depression and suicidal ideation. Prospective studies are
therefore needed to determine the sequence of events that lead
to suicidal ideation among persons in midlife and older who are
living with HIV-AIDS.
Our study is further limited by its reliance on self-reported
states of emotional and physical health. Moreover, our
convenience sample included only subjects who were connected
with AIDS service agencies. The rates of emotional distress and
suicidal ideation observed in our sample may differ from those
of persons who are not receiving services.
Use of a single questionnaire item to assess suicidal ideation
is another limitation of our study. Future research should use
more comprehensive measures to assess the frequency, duration,
and extent of suicidal thoughts in middle-aged and older people
with HIV-AIDS. Finally, our overall sample was relatively small,
and the number of people within it considering suicide was even
smaller. Thus our findings must be viewed as preliminary and in
need of replication and extension.
Conclusions
HIV-AIDS is no longer considered an epidemic of the young.
Issues connected with death and dying likely are different in
persons who are middle-aged and older than in younger persons.
Interventions designed for people who have HIV-AIDS should be
tailored to reflect their relevant developmental contexts.
Persons who are middle-aged and older who are living with
HIV-AIDS and are at risk for suicide require comprehensive
mental health services, given the breadth and depth of their
emotional distress and functional limitations. Such services may
be integrated with available HIV care systems such as case
management and multiservice agencies. Counseling, enhancing
perceived support, and increasing coping resources for persons
who have thoughts of suicide but are not yet in need of crisis
intervention should be considered a priority in HIV-AIDS care
services.
Acknowledgments
This research was supported by grant R03-AG-16034 from the
National Institute of Aging and grants R01-MH-57624 and
P30-MH-52776 from the National Institute of Mental Health.
Footnotes
The authors are affiliated with the Center for AIDS Intervention
Research at the Medical College of Wisconsin in Milwaukee, 8701
Watertown Plank Road, Milwaukee, Wisconsin 53226 (e-mail,
sethk@mcw.edu ).
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