Mental health in the era of HIV. Investigating mental distress, its determinants, conceptual models and the impact of HIV in Zambia

Background: Population level data on mental health from Africa are limited, but available data indicate mental problems to represent a substantial public health problem. The negative impact of HIV on mental health suggests that this could particularly be the case in high prevalence populations. We examined the prevalence of mental distress, distribution patterns and the ways HIV might influence mental health among men and women in a general population. Methods: The relationship between HIV infection and mental distress was explored using a sample of 4466 participants in a population-based HIV survey conducted in selected rural and urban communities in Zambia in 2003. The Self-reporting questionnaire-10 (SRQ-10) was used to assess global mental distress. Weights were assigned to the SRQ-10 responses based on DSM IV criteria for depression and a cut off point set at 7/20 for probable cases of mental distress. A structural equation modeling (SEM) was established to assess the structural relationship between HIV infection and mental distress in the model, with maximum likelihood ratio as the method of estimation. Results: The HIV prevalence was 13.6% vs. 18% in the rural and urban populations, respectively. The prevalence of mental distress was substantially higher among women than men and among groups with low educational attainment vs. high. The results of the SEM showed a close fit with the data. The final model revealed that self-rated health and self perceived HIV risk and worry of being HIV infected were important mediators between underlying factors, HIV infection and mental distress. The effect of HIV infection on mental distress was both direct and indirect, but was particularly strong through the indirect effects of health ratings and self perceived risk and worry of HIV infection. Conclusion: These findings suggest a strong effect of HIV infection on mental distress. In this population where few knew their HIV status, this effect was mediated through self-perceptions of health status, found to capture changes in health perceptions related to HIV, and self-perceived risk and worry of actually being HIV infected. Published: 18 August 2009 BMC Public Health 2009, 9:298 doi:10.1186/1471-2458-9-298 Received: 18 November 2008 Accepted: 18 August 2009 This article is available from: http://www.biomedcentral. com/1471-2458/9/298 © 2009 Chipimo and Fylkesnes; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. BMC Public Health 2009, 9:298 http://www.biomedcentral. com/1471-2458/9/298 Page 2 of 11 (page number not for citation purposes) Background Mental disorders make a substantial independent contribution to the burden of disease worldwide. It is estimated that, neuropsychiatric conditions account for up to 15% of all disability-adjusted life-years, and up to 30% of those attributable to non-communicable diseases. Neuropsychiatric disorders also account for 1.2 million deaths every year. [1,2] These figures are most likely underestimated as official statistics in low and middle income countries are scanty and unreliable. [2] In sub-Saharan Africa, it has been reported that 20–30% of primary health care centre attendees present with depressive symptoms as the first or secondary reason for seeking medical care. [3] A study conducted in Tanzania revealed a 41.6% prevalence of depressive symptoms among primary health care patients while a similar study in Uganda reported a 20–30% prevalence of psychological disorders and depression among health care seekers. [4,5]. These research findings have also shown heightened risk for common mental disorders among the women i.e. a female to male ratio of 1.5–2.0. Other determinants have been found to include low socioeconomic position indicated by poor access to resources, unemployment and low educational attainment. It has also been shown to be higher among those with poor socio-support networks such as the unmarried, widowed and divorced. [6-8] Mental disorders interact with many other health conditions, thus predicting the onset and progression of both physical and social disability. Several studies have established independent associations between mental disorders and an excess in all-cause mortality risk. In a metaanalysis, Saz and Dewey found pooled odds ratio of 1.7 for a diagnosis of depression and subsequent all-cause mortality. [9] Of particular relevance for this investigation is the interaction between mental disorders and HIV infection. Evidence has shown a heightened risk for contracting HIV infection among those with mental disorders. [10,11] Socioeconomic, psychological and biological factors [1,12-14] have been reported as predisposing factors in HIV infection and have also been found to be relevant factors in mental distress related HIV disease progression. [1,12]. Mental disorders can also mediate delayed help seeking, diagnosis, poor compliance to medication [15] and can predict drop out from HIV-risk reduction programmes. [16,17] Although evidence from low income countries is limited, fairly consistent associations have been reported between HIV and poor mental health with most published studies showing differing but high percentages of mental distress, e.g. observations from South Africa with prevalence of 40% contrasting a study in rural Ethiopia showing14%. [18,19] A meta-analysis of studies comparing HIV positive and HIV negative groups revealed a significant difference in the prevalence of major depression (HIV positive 9.4% vs. HIV negative 5.2%, OR 2.0, CI 1.3– 3.0). [20] These studies have indicated that mental distress can be prevented by increasing the awareness about it among mental health personnel. [10,11] The benefit of screening for mental distress is especially important among the HIV infected. Left undiagnosed mental distress leads to failure of the HIV positive to deal with their serostatus [19] with implications of increased substance abuse and suicides. All these put together build the case for early identification of patients with mental distress and prompt psychotherapy [21]. Despite the known benefits, the practice of screening for mental distress as it relates to HIV infection is still low in many countries. In Zambia, little is known about the extent of mental distress. [22] Considering that Zambia has a high prevalence of HIV [14,23,24] and assuming that HIV infection negatively affects mental health, this would suggest that the mental distress problem is substantial. However, few population based studies, i.e. covering men and women in the general population, have been conducted in sub-Saharan Africa to examine the relationship between HIV and mental distress. The aim of this study was to investigate the magnitude and determinants of mental distress with particular emphasis on the mechanisms involved in the way HIV infection impacts mental distress by establishing a linear structural equation model. Methods Measuring mental distress A wide variety of questionnaires and instruments have been developed over the years to estimate psychological distress in the population, identify high risk groups for mental disorders and monitor the changes over time. The Self reporting questionnaire (SRQ) is an example of such a scale developed as part of a collaborative study on strategies for extending mental health care co-ordinated by the WHO. [11] Although primarily intended for use in epidemiological studies of mental disorders, it is also being used extensively for clinical and other research purposes. [11] It has been judged to be acceptable for most subjects and was found to be appropriate for use in different kinds of settings and countries. [11,19,25] It is now a well established responder-reported questionnaire for measuring psychological distress or the degree of global mental distress [11]. In this study we use a Self reporting questionnaire with 10 symptom questions which are scored on a dichotomous scale but do not probe to evaluate symptom severity [11]. It has also been shown that the shorter SRQ10 performs just as well as the longer scales for evaluating mental distress, for example SCL-25 and SF-36 as well as other shorter scales such as SCL-10, SCL-5 and MHI-5. It BMC Public Health 2009, 9:298 http://www.biomedcentral. com/1471-2458/9/298 Page 3 of 11 (page number not for citation purposes) has been suggested that it can be used in the place of longer scales for evaluating mental distress and yield comparable results. [25] The model In this model, a set of several linear equations are connected in a system. Our central theoretical premise is that mental distress has biological, social and psychological determinants. Therefore four hypotheses have been developed and require further testing. Firstly, we propose that, demographic characteristics and socioeconomic position indicators are directly and indirectly associated with mental distress. [19] Male gender, young age, (15–25 years), educational attainment, social support networks (being married vs. single) and wealth index are found to be positively associated with better mental health status. [26] Secondly, self-rated health, and self HIV risk perception and worries of being infected (HIV risk and worry) are also associated with better mental health. [27] Thirdly, we propose that HIV infection has both direct and indirect effects on mental distress. [27] Direct, mediated by biological factors and indirectly mediated through self-rated health and HIV risk and worry of being infected. [27,28] Population and Sampling Procedures The population-based HIV surveys have been conducted in Zambia every third year since 1996 in selected rural (Kapiri Mposhi) and urban (Chelston) communities. For this investigation we used data from the survey co