CASE DEFINITION: SCREENING

Depression and anxiety disorders represent the most common mental disorders in people living with HIV/AIDS (PLWHA). However, they often go undiagnosed, untreated or trivialized as ‘understandable sadness’, given the emotional gravity of a positive HIV diagnosis [1]. Studies of their prevalence, severity or impact on affected individuals in low- and middle-income countries (LMIC) are often compromised by the lack of uniform study methodologies and instruments, the latter having often been developed in the West and not validated in the LMIC communities where they are used [2]. Thus, we get varying prevalence rates of these disorders, which makes comparisons with high-income countries difficult. Nevertheless, it is widely accepted that the presence of these mental disorders compromises treatment outcome and slows down HIV infection preventative efforts. A recent systematic review comparing the accuracy of brief versus long depression screening instruments that have been validated in LMIC found significant heterogeneity between the studies (X[2] = 189.23, df = 18, p < 0.001), thus rendering a meta-analysis impossible [2]. Akena et al. [3] compared the sensitivity and specificity of three depression screening instruments in HIV-positive patients (PHQ-9, CES-D and K-10) and found the PHQ-9 to be the most sensitive and specific, hence its recommendation as the depression screening instrument of choice in LMIC. A PHQ-9 score of ≥10 approximates to a Diagnostic and Statistical Manual of Mental Disorders-4th edition (DSM-IV) diagnosis of major depressive episode in 99% of cases. Screening instruments for anxiety disorders have not had as much scrutiny as those for screening for depression, hence giving even less certain prevalence rates with much variation, for example, 0–60%.

CAUSATION AND DIAGNOSIS

As to whether the depression seen in HIV-positive individuals is primary (as in primary affective disorder) or secondary (to HIV CNS (central nervous system) infection, the various medications used, substance use or a psychological reaction to HIV diagnosis) is a subject of much importance. It has a bearing on treatment, prevention and prognosis. Moreover, it is true that both primary depressive illness and secondary depressive illness occur in HIV/AIDS. It therefore behoves the clinician to distinguish the two for corrective treatment. News of a positive test diagnosing HIV infection often invokes much emotion, leading to panic, anxiety and an adjustment disorder that often will be of a depressive type, and which, if untreated, will progress to a major depressive episode, necessitating antidepressant medications. On the other hand, a purely psychological reaction will respond very well to psychological therapies. However, early subcortical involvement of the CNS by the HIV virus often produces a biological depression that may even manifest before one knows that he or she is HIV-positive – in the so called asymptomatic phase [1]. This will only respond to antidepressant medication, however mild in severity and at whatever stage of the HIV disease. Studies of this HIV-associated secondary depressive illness show it to be different from the depression of a primary affective disorder (as in recurrent unipolar or bipolar depression) and certainly different from an adjustment disorder with depressed mood [4]. Compared to primary affective disorder depression, HIV-related depression tends to have a later onset in life, occur in older individuals (≥30 years) and not be associated with a family history of affective disorder; but it is more likely to be associated with cognitive impairment [4]. In studies of depression in HIV/AIDS, it is therefore very important to differentiate these various depressions both for epidemiological and treatment purposes. Very few studies have tried to do this.

PREVALENCE

Many studies have put the prevalence of depression in HIV/AIDS to be 20–40% with an average of 30% [56789]. Most of these studies, however, do not differentiate between the various types of depression. Those that do give the prevalence of any

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