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2 New studies: Diabetes-Depression-Women
& High Suicide Rates PLWH
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2 new studies of great interest: 1 - people with type 2 diabetes have high rates (18%) of anxiety especially among women ;
2 - Suicide rates high among PLWH: suicide death is 100-fold higher in people living with HIV. these data suggest that PLWHA are at high risk for attempting suicide. Such observation requires appropriate interventions in those at the highest risk.
new study published:
"More anxious than depressed: prevalence and correlates in a 15-nation study of anxiety disorders in people with type 2 diabetes mellitus"
people with type 2 diabetes have a high prevalence of anxiety disorders, especially women,those with diabetic complications, those with a longer duration of diabetes and poorer glycaemic control. Early identification and appropriate timely care of psychiatric problems of people with type 2 diabetes is warranted........ .It is likely that anxiety may be a protective factor for diabetes complications as anxious people may consult more for minor symptoms and ailments.................A total of 3170 people with type 2 diabetes (56.2% women; with mean (SD) duration of diabetes 10.01 (7.0) years) participated..........The International Diabetes Federation recommends regular screening for psychological problems such as depression,47 and the findings of this present study extend this to anxiety......... The overall prevalence of anxiety disorders in type 2 diabetic persons was 18%; however, 2.8% of the study population had more than one type of anxiety disorder. The most prevalent anxiety disorders were generalised anxiety disorder (8.1%) and panic disorder (5.1%). Female gender, presence of diabetic complications, longer duration of diabetes and poorer glycaemic control (HbA1c levels) were significantly associated with comorbid anxiety disorder. A higher prevalence of anxiety disorders was observed in Ukraine, Saudi Arabia and Argentina with a lower prevalence in Bangladesh and India.
https://gpsych.bmj.com/content/32/4/e100076
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new study published:
Rates and risk factors for suicidal ideation, suicide attempts and suicide deaths in persons with HIV: a systematic review and meta-analysis
https://gpsych.bmj.com/content/34/2/e100247
This systematic review and meta-analysis aimed to assess the lifetime incidence and prevalence of suicidality in PLWHA.
Conclusions The risk of suicide death is 100-fold higher in people living with HIV than in the general population. Lifetime incidence of suicidal ideation and attempts are substantially high. Suicide risk assessments should be a priority in PLWHA, especially for those with more advanced disease.
Our search retrieved 1518 articles, of which 539 full-texts were carefully reviewed and considered as potentially relevant (PRISMA; figure 1). The full-text review identified 40 eligible articles from 14 countries (table 1): USA 15, France 5, Brazil 3, Switzerland 3, South Africa 1, China 3, Canada 2, Australia 1, Italy 1, South Korea 1, Greece 1, Uganda 1, UK 2 and Netherlands 1
Main findings
About 40 million people of the global population are currently living with HIV/AIDS.3 32 The era of HAART treatment has brought significant improvements in patient longevity and quality of life; however, PLWHA experience a heavy burden of psychosocial conditions that are frequently undiagnosed and untreated. In our study, the pooled incidence of suicide completion among PLWHA globally was 10.2 per 1000 (95%CI: 4.5 to 23.1), translating to a 100-fold greater suicide completion rate compared with the global population rate of 0.11/1000.33 While the suicide completion rate was twice as high in North America (20.4/1000, 95%CI: 2.43 to 150.16), compared with that in Europe (8.4/1000, 95%CI: 3.69 to 19), this difference was not significant. Importantly, the most striking difference found was between the prevalence of suicide attempts across the geographic regions. While we found a pooled global prevalence of suicide attempts at 158.3/1000 in PLWHA, the pooled prevalence of suicide attempt in this cohort was highest in North America, South America and Australia at 212.6/1000 (95%CI: 123.5 to 314.2), 232.2/1000 (95%CI: 180.2 to 294.0) and 213.4/1000 (95%CI: 157.4 to 282.7), respectively. This is in striking comparison to a global lifetime suicide attempt prevalence of 3% in the general population.34 Additionally, the overall pooled prevalence of suicidal ideation in PLWHA was 228.3/1000 (95%CI: 150.8 to 330.1). This is markedly increased compared with the global suicidal ideation rate of 9% in the general population.34 Collectively, these data suggest that PLWHA are at high risk for attempting suicide. Such observation requires appropriate interventions in those at the highest risk.
Implications
Globally in the general population, one out of every three individuals with suicidal ideation will attempt it, and one out of every 286 attempts will be completed. Our results suggest that in PLWHA for every 2 individuals with suicidal ideations, there is one individual with a suicide attempt, and for every 13 suicide attempts, one person may complete suicide. This is indicative of an increased risk in PLWHA for completed suicide than that of the general population, thus prompting further examination into the characteristics pertinent to these findings.
Determinants for an increased risk of suicide in PLWHA are multifactorial. They include the physiological effects of HAART or decreased CD4 count, neurological symptoms in patients categorised as having neuro HIV, the stigma that is still associated with the disease or the effect of disease on interpersonal relationships.35 36 In our meta-regression analysis in which we explored the risk factors of suicide, stage V disease (AIDS) was significantly associated with the risk of suicide completion. This relationship is not surprising considering that this stage is associated with high a viral load, fostering a direct effect of the virus on the brain. Previous studies have found a higher CD4 count to have a protective effect on suicide completion. In a recent study exploring seizure frequency in PLWHA, the advanced stage of HIV was significantly associated with new-onset seizures. The author argued that direct brain injury, possibly caused by the virus, could be a potential mechanism of brain injury.37 Further work should be conducted to determine the mechanisms by which the progression of HIV modulates the risk of suicide completion.
Of note, data have shown that suicide rates are extraordinarily high in PLWHA within the first year of diagnosis.38 Taking this into consideration with our results, there may be a bimodal distribution for excessive suicide risk within the first year of diagnosis and if the disease progresses to stage V. Given our results, we suggest the most effective actionable targets to reduce the rate of suicidal ideation, attempt and completion is immediate and routine suicide risk assessment, psychological counselling and mental health treatment in conjunction with antiviral treatment to maintain or increase CD4 counts. These intervention strategies have been shown to reduce depression and suicide.39
Preliminary studies have shown that brief interventions for suicide prevention can be used shortly after diagnosis, which reduces suicidal ideation when compared with standard post-test counselling.40 Alternatively, internet-based counselling is effective at reducing depressive symptoms in PLWHA in a randomised control trial in the Netherlands.41 Furthermore, several studies have found that spiritual engagement has a protective effect against suicidal ideation in PLWHA within different cultural communities.13 42 43 Health providers should thus consider embracing established interventions, encouraging PLWHA to engage with their preferred form of spirituality in a culturally competent manner and treating to increase or maintain CD4 counts to reduce suicidal ideation and completion. Further work should be done to characterise the efficacy of these interventions to reduce suicidal ideation, attempts and completion in PLWHA.
Conclusion
Within this meta-analysis, we demonstrate for the first time that across an extensive and diverse patient cohort, the rate of suicide deaths in PLWHA is 100-fold higher than the rate that has been reported in the general population. This risk is directly associated with HIV progression; however, antiretroviral treatment and higher CD4 counts seem to be protective against suicide attempts. Lastly, we show that within cohorts of PLWHA, there are regional differences in suicide risk with especially profound rates in North America. We suggest that suicide risk assessment be provided to PLWHA in conjunction with antiviral treatment to improve clinical outcomes, patient longevity and quality of life.
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