Common Mental Disorders among HIV-Infected Individuals in South ...

AIDS PATIENT CARE and STDs Volume 22, Number 2, 2008 © Mary Ann Liebert, Inc. DOI: 10.1089/apc.2007.0102

Common Mental Disorders among HIV-Infected Individuals in South Africa: Prevalence, Predictors, and Validation of Brief Psychiatric Rating Scales LANDON MYER, Ph.D.,1,2 JOALIDA SMIT, M.A.,3 LIEZEL LE ROUX, B.Cur.,3 SIRAAJ PARKER, M.A.,3 DAN J. STEIN, M.D., Ph.D.,3,4 and SORAYA SEEDAT, F.C.Psych (SA), Ph.D.3

ABSTRACT Despite the high prevalence of both mental disorders and HIV infection in much of sub-Saharan Africa, little is known about the occurrence of mental health disorders among HIV-infected individuals. We conducted a cross-sectional study among individuals enrolled into HIV care and treatment services near Cape Town, South Africa. Psychiatric diagnoses were measured using the Mini-International Neuropsychiatric Interview (MINI) administered by trained research nurses. In addition, all participants were administered brief rating scales for depression (the Center for Epidemiological Studies Depression Scale [CES-D]), posttraumatic stress disorder (PTSD), the Harvard Trauma Questionnaire (HTQ), and alcohol dependence/abuse (the Alcohol Use Disorders Identification Test [AUDIT]). The median age among the 465 participants was 33 years and 75% were female; 48% were receiving antiretroviral therapy. Overall, the prevalence of depression, PTSD and alcohol dependence/abuse was 14% (n 62), 5% (n 24), and 7% (n 35), respectively. In multivariate analysis, the prevalence of all disorders was significantly higher among individuals who spoke Afrikaans compared to Xhosa. While the AUDIT showed excellent sensitivity and specificity in detecting MINIdefined dependence/abuse (area under the receiver-operating characteristic curve, 0.96), the HTQ and CES-D had lower performance characteristics in detecting PTSD (0.74) and depression (0.76), respectively. These data demonstrate high levels of depression, PTSD and alcohol dependence/abuse among HIV-infected individuals in this setting. Additional research is required to refine these rating scales for maximum applicability in cross-cultural populations. More generally, HIV care and treatment services represent an important venue to identify and manage individuals with common mental disorders in resource-limited settings. INTRODUCTION

H

IV/AIDS AND MENTAL ILLNESS make substantial contributions to the burden of disease in developing countries, and in sub-Saharan Africa in particular. There are an estimated

25 million individuals living with HIV across Africa.1 Although there are few data on the population prevalence of mental illness in African countries, estimates from the World Mental Health Survey suggest that the burden of mental illnesses may be substantial, with

1Infectious Diseases Epidemiology Unit, School of Public Health & Family Medicine, 4Department of Psychiatry, University of Cape Town, Cape Town, South Africa. 2Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York. 3MRC Unit on Anxiety and Stress Disorders, University of Stellenbosch, Cape Town, South Africa.

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particular concern regarding the common mental disorders of depression, post-traumatic stress disorder, and substance abuse.2 Importantly, the role that these conditions play in population health is likely to continue in the coming decades: the Global Burden of Disease Survey estimated that by the year 2020, mental illness and HIV/AIDS will both be in the top 10 causes of morbidity in developing countries.3 There are few insights into the interactions between the dual epidemics of HIV infection and mental illness in sub-Saharan Africa. Research from Europe and North America has suggested that HIV may affect mental health in different ways over time. Early in the course of HIV disease, the psychosocial impact of an HIV diagnosis, a universally fatal and often stigmatized disease, presents a significant stressor that may increase the prevalence of mental disorders.4,5 Several studies have suggested that depressive and anxiety disorders may speed the progression of HIV disease.6,7 Such an influence may be mediated by changes in medication adherence, willingness to access health care, interactions with health care providers, and other health-promoting behaviors among individuals with mental disorders.8,9 With advancing HIV disease, the neuropsychiatric effects of the virus contribute to more marked mental illness with presentations of HIV-related dementia and psychosis.10 Meanwhile, mental illnesses may increase high-risk behaviors for the further transmission of HIV.11,12 Despite the importance of HIV and mental illness in shaping population health, only a handful of studies have examined mental illness among HIV-infected individuals in sub-Saharan Africa. In a study of 149 individuals who were recently diagnosed with HIV, Olley et al.13,14 showed substantial prevalence of both major depression (35%) and post-traumatic stress disorder (15%). While this study suggests that the burden of mental illness among HIV-infected individuals may be considerable, further research is clearly needed to establish the distribution and determinants of psychopathology among HIV-infected individuals in different settings as well as the mechanisms through which HIV influences mental health status.

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To date, research focusing on mental health and HIV in Africa has been hindered by the lack of simple, validated screening tools.15 There have been few published validation studies of brief assessment instruments to detect mental illness in HIV-infected populations in sub-Saharan Africa.16,17 Without brief measures that can be used to detect common mental illnesses, researchers are forced to rely on longer schedules that require considerable interviewer training to administer reliably, so presenting a significant barrier to evaluating mental health status in individuals infected with or at risk of HIV. To address this concern we conducted a study of the prevalence and predictors of common mental disorders among HIV-infected individuals, including a validation study of brief rating scales to measure the three most common mental disorders in sub-Saharan Africa: depression, posttraumatic stress disorder (PTSD), and alcohol abuse and dependence.

MATERIALS AND METHODS Setting and participants The study took place between October 2004 and December 2005 at three primary level HIV care and treatment services in Cape Town, South Africa. All care at these public sector facilities, including antiretroviral therapy, is provided free of charge. All three facilities provide both general HIV care as well as antiretroviral therapy. Participants were patients receiving care at the facilities and were eligible for the study if they had tested HIV-positive according to medical records, were between the ages of 18 and 65, had a Mini-Mental State Exam (MMSE) score of greater than 24; and could provide written informed consent for questionnaire administration and clinician access to medical records. Study procedures Data were collected in two separate interviews carried out on the same day as their routine clinic visits. The first interview lasted approximately 30 minutes and focused on participant demographic characteristics and

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the screening tools for depression, PTSD and alcohol dependence/abuse, and was administered by trained interviewers. Following this, participants received a separate, structured clinical interview administered by one of two trained research nurses working in the participants’ home language (either Afrikaans or Xhosa). In this setting, Afrikaans speakers are largely from the so-called “colored” population group, individuals of mixed ancestry with social and cultural traditions that are largely distinct from those of black African Xhosa speakers. There is some suggestion that the interpretation of psychiatric symptoms may differ by linguistic group, though this has received relatively little empirical attention, particularly in the context of HIV/AIDS.18 The clinical interviewers were blinded to all data collected during the preliminary interview. After both interviews were completed, clinic staff extracted basic clinical and immunologic data from participants’ most recent clinic visits. All interviews took place in private rooms at each facility. Participants received reimbursement for transport costs, for up to a maximum of R30 ($4). Ethical approval to conduct this research was provided by the Committee for Human Research of the University of Stellenbosch. Screening tools Screening tools for PTSD, alcohol dependence/abuse, and depression were selected based on their ease of administration and existing evidence for cross-cultural administration. Individuals with possible PTSD were identified using the Life Events Checklist to identify events that would qualify as a traumatic or life threatening as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), including vicarious trauma. Participants who noted any traumatic life events went on to complete the Harvard Trauma Questionnaire (HTQ), a 30-item selfrating questionnaire that has specifically been developed to screen for the presence of PTSD in cross-cultural populations19 and has been used in other contexts in South Africa.20 Screening for alcohol abuse or dependence was based on the Alcohol Use Disorders Iden-

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tification Test (AUDIT). This is a 10-item, selfrating questionnaire that assesses hazardous drinking. The AUDIT was developed and validated by the World Health Organisation for international use21 and has been validated for a variety of community and primary health care settings, including in southern Africa.22,23 Depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D). This is a 20-item self-rating scale that assesses current levels of depression as per the DSM-IV criteria. This measure has been validated for use in community and clinic settings to detect the presence of depressive symptoms in North America24 and has been validated in many international samples including South Africa.25 Psychiatric diagnoses The Mini-International Neuropsychiatric Interview (MINI) was used as the gold-standard structured diagnostic interview. The MINI was designed as a brief structured interview across the major Axis I psychiatric disorders in the DSM-III-R, DSM-IV, and ICD-10 based on a standardized algorithm of questioning.26 The MINI has been validated against the Structured Clinical Interview for DSM III-R diagnoses and has been used as a gold standard in cross-cultural studies across the world, including in a sample of HIV-infected patients in South Africa.13,14 Analysis Data were analyzed using Stata version 9.2 (College Station, TX). 2 tests were used to compare proportions, replaced by exact tests for sparse data; means and medians were compared using Student’s t and Wilcoxon ranksum tests, respectively. To investigate the independent associations between participant sociodemographic or HIV disease characteristics and mental illness, we developed separate multiple logistic regression models predicting MINI-defined depression, PTSD and alcohol abuse and/or dependence. Variables were entered into each model if they demonstrated an appreciable association in bivariate analyses, and were retained if their association with the mental illness outcome persisted after multiple statistical adjustments or if their removal al-

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tered associations involving other covariates. Model checking and diagnostics followed standard procedures.27 The performance of each screening test in measuring MINI-defined psychopathology was first examined using sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals (CI). The MINI-based diagnoses used as gold standards were current major depressive disorder (to validate the CES-D), PTSD (to validate the HTQ) and current alcohol abuse or dependence (to validate the AUDIT). We analysed the HTQ based on its full 30 items, and also restricted to its first 16 items only, which are based on the diagnostic criteria for PTSD in the DSM-IV. The clinical utility of the measures was assessed with positive and negative likelihood ra-

tios (LR and LR-, respectively) to estimate the likelihood that a screening test result (positive or negative) would occur in an individual with a given psychiatric disorder compared to the likelihood that that same result would be expected in a patient without that disorder.28 Nonparametric receiver operating characteristic curve analysis was used to analyze the overall performance of each screening test, and to compare the test characteristics in subgroups of participants.29 All statistical tests are twosided at 0.05. RESULTS A total of 465 participants with data for each screening test and MINI-defined mental illness

TABLE 1. DESCRIPTION OF THE STUDY SAMPLE OF FOUR HUNDRED SIXTY-FIVE HIV-INFECTED INDIVIDUALS ENROLLED HIV CARE AND TREATMENT SERVICES IN CAPE TOWN, SOUTH AFRICA, OVERALL AND BY HOME LANGUAGE

IN

Home language Total (n 465) Sociodemographics Median age in years (IQR) n (%) Female Language: Xhosa Language: Afrikaans Language: English/other Married/in a relationship Completed primary education Employed Income R200/week HIV disease On ART Median time since HIV diagnosis (months) Median CD4 count CD4 count 200 MINI-defined psychopathology Major depressive episode Posttraumatic stress disorder Alcohol abuse Alcohol dependence Alcohol abuse or dependence Brief rating scales for psychopathology AUDIT-defined alcohol abuse CES-D–defined depression HTs-defined PTSD

Xhosa n 309

Afrikaans n 118

Other n 38

33 (28–37) 246 (80) — — — 222 (72) 264 (86) 65 (21) 253 (82)

34 (29–39) 74 (63) — — — 67 (57) 98 (84) 43 (36) 81 (69)

33 (29–40) 30 (79) — — — 19 (50) 37 (97) 11 (29) 29 (76)

0.044 0.001

224 (48) 29

146 (47) 28

52 (44) 33

26 (68) 30

0.017 0.144

234 174 (37)

230 120 (39)

245 40 (34)

228 14 (37)

0.563 0.649

33 350 309 118 38 308 399 119 350

63 24 5 30 35

(29–38) (75) (66) (25) (9) (66) (86) (26) (75)

(14) (5) (1) (6) (7)

126 (27) 208 (45) 99 (21)

26 6 2 8 10

(8) (2) (1) (3) (3)

77 (25) 144 (47) 70 (23)

35 17 3 20 23

(30) (14) (3) (17) (19)

42 (35) 50 (42) 21 (18)

2 1 0 2 2

(5) (1) (2) (2)

7 (18) 14 (37) 8 (21)

p valuea

0.001 0.072 0.005 0.013

0.001 0.001 0.231 0.001 0.001 0.043 0.445 0.555

ap values are for the global comparison of home language groups, using exact tests (for proportions) and KruskallWallis tests (for medians). All cells are N(%) unless otherwise specified. ART, antiretroviral therapy; MINI, Mini-International Neuropsychiatric Interview; AUDIT, Alcohol Use Disorders Identification Test, CES-D, Centers for Epidemiological Studies Depression Scale; HTQ, Harvard Trauma Questionnaire; PTSD, posttraumatic stress disorder.

(70) (41) (56) (3) (67) (82) (30) (22)

24 (39) 25 257 19 (30)

33 44 26 35 2 42 51 19 14

All cells are n(%) unless otherwise specified.

Sociodemographics Median age in years N(%) Female Language: Xhosa Language: Afrikaans Language: English/other Married/in a relationship Completed primary education Employed Household income R200/week HIV disease On ART Median months since HIV diagnosis Median CD4 count CD4 count 200

Present n 63

(76) (70) (21) (9) (66) (87) (25) (22)

201 (53) 30 232 155 (38)

33 307 283 83 36 267 349 100 88

Absent n 402

0.043 0.001 0.641 0.210

0.928 0.359 0.360 0.953

0.147 0.278 0.001

p value

Major depressive episode

(79) (25) (71) (4) (46) (83) (21) (8)

13 (54) 30 236 8 (33)

34 19 6 17 1 11 20 5 2

Present n 24

(75) (69) (23) (8) (68) (86) (26) (23) 211 (51) 29 233 166 (38)

33 331 303 101 37 297 379 114 100

Absent n 441

0.769 0.606 0.966 0.671

0.030 0.678 0.583 0.098

0.496 0.662 0.001

p value

Posttraumatic stress disorder

(40) (29) (66) (6) (71) (97) (46) (37) 10 (29) 34 274 9 (26)

33 14 10 23 2 25 34 16 13

Present n 35

(78) (70) (22) (8) (66) (85) (25) (21) 214 (53) 29 224 165 (38)

33 336 299 95 36 283 365 103 89

Absent n 430

0.008 0.285 0.150 0.137

0.499 0.051 0.005 0.024

0.610 0.001 0.001

p value

Alcohol abuse or dependence

TABLE 2. ASSOCIATION BETWEEN MINI-DEFINED PSYCHOPATHOLOGY AND PARTICIPANT SOCIODEMOGRAPHIC AND HIV DISEASE CHARACTERISTICS AMONG FOUR HUNDRED SIXTY-FIVE HIV-INFECTED INDIVIDUALS ENROLLED IN HIV CARE AND TREATMENT SERVICES IN CAPE TOWN, SOUTH AFRICA

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were included in the analysis (Table 1). The median age of participants was 33 years and three quarters were female. Slightly less than half of participants were receiving antiretroviral therapy at the time of the study, and 37% had a CD4 count below 200 cells per microliter. Compared to individuals who spoke Afrikaans, participants who spoke Xhosa were more likely to be younger, female, married, unemployed and have an income below R200 per week. Overall, 19% of participants (n 88) were found to have at least one MINI-defined disorder. Sixty-two participants (14%) had a major depressive episode in the previous 12 months and 24 (5%) had PTSD. One percent of the sample (n 5) had MINI-defined alcohol abuse, but an additional 30 individuals (6%) met criteria for alcohol dependence. Thirty participants (6%) had multiple disorders (approximately one third of those with any mental illness), primarily involving depression and alcohol abuse/dependence (n 19). Table 2 shows the unadjusted associations between each disorder and participant sociodemographic and HIV disease characteristics. Across all three disorders, patients who spoke Afrikaans were significantly more likely to experience MINI-defined psychopathology than patients who spoke Xhosa, English, or another language. In addition, patients with a recent major depressive episode were less likely to be taking ART, and had a shorter time since their HIV diagnosis; patients with MINI-de-

fined PTSD were less likely to be married or in a relationship; and patients with MINI-defined alcohol abuse or dependence were more likely to be male, unemployed, have an income of less that R200 (US $30) per week, and not receiving ART. In multivariate analysis (Table 3), the prevalence of all disorders remained significantly associated with speaking Afrikaans compared to Xhosa. In addition, depression was associated with decreasing age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.92–0.99); PTSD was inversely associated with higher household incomes (OR, 0.12; 95% CI, 0.02–0.88); and alcohol abuse/dependence was inversely associated with female gender (OR, 0.19; 95% CI, 0.08–0.43). The test characteristics of each brief rating scale are shown in Table 4. The sensitivity and specificity of the CES-D in detecting MINI-defined depression was 79% (95% CI: 76%–83%) and 61% (95% CI: 56%–85%), respectively (LR 2.2; LR- 0.3). The test characteristics were significantly improved among individuals who spoke Afrikaans (p 0.007) and individuals with CD4 counts above 200 cells per microliter (p 0.017). The AUDIT correctly identified all individuals with MINI-defined alcohol abuse or dependence (sensitivity, 100%) and correctly classified 79% of individuals who did not have alcohol abuse or dependence (95% CI: 75%–83%) (LR 4.7; LR- 0.8). The test characteristics did not vary significantly across subgroups.

TABLE 3. RESULTS OF MULTIPLE LOGISTIC REGRESSION MODELS PREDICTING ODDS RATIOS (OR) AND 95% CONFIDENCE INTERVALS (CI) FOR MINI-DEFINED DEPRESSION, POSTTRAUMATIC STRESS DISORDER AND ALCOHOL ABUSE OR DEPENDENCE, AMONG FOUR HUNDRED SIXTY-FIVE HIV-INFECTED INDIVIDUALS ENROLLED IN HIV CARE AND TREATMENT SERVICES IN CAPE TOWN, SOUTH AFRICA Major depressive episode

Age in years N (%) Female Language: Xhosa Language: Afrikaans Language: English/other Married/in a relationship Completed primary education Household income R200/week Currently employed



OR

95% CI

OR

95% CI

OR

95% CI

0.96 0.82 1.00 4.90 0.72 1.11 0.72 0.60 1.42

0.92–0.99 0.43–1.57 (reference) 2.66–9.02 0.16–3.21 0.61–2.06 0.33–1.59 0.20–1.73 0.53–3.75

0.96 1.41 1.00 12.20 1.48 0.47 1.00 0.12 1.92

0.90–1.020 0.47–4.250 (reference) 4.19–35.57 0.16–13.49 0.19–1.180 0.28–3.560 0.02–0.880 0.46–8.020

0.96 0.19 1.00 7.98 2.14 1.56 9.55 0.67 2.29

0.91–1.010 0.08–0.430 (reference) 3.30–19.33 0.42–10.97 0.65–3.730 1.17–77.77 0.17–2.660 0.60–8.640

MINI, Mini-International Neuropsychiatric Interview.

79.4% 76.5% 82.8% 84.1% 68.4% 73.1% 85.7% 75.0% 82.1% 63.2% 86.4%

n 63

n 34

n 29

n 44

n 19

n 26

n 35

n 24

n 39

n 19

n 44 61.9%

58.4%

58.7%

62.5%

75.9%

55.7%

67%.0

58.5%

52.4%

62.8%

60.6%

Spec

28.8%

15.8%

27.8%

19.4%

60%.0

13.2%

25.9%

22.6%

22.2%

26.0%

24.0%

PPV

96.2%

92.8%

94.4%

95.4%

92.6%

95.7%

21.3%

96.2%

95.9%

94.0%

94.9%

NPV

n 16

n 80

n 11

n 13

n 17

n 60

n 50

n 19

n 13

n 11

n 24

N

50%.0

12.5%

36.4%

38.5%

47.1%

0%

60.0%

31.6%

46.2%

27.3%

37.5%

Sens

79.6%

79.5%

79.1%

80.1%

87.1%

76.9%

81.7%

78.9%

79.8%

79.4%

79.6%

Spec

12.5%

2.9%

7.7%

10.6%

38.1%

0%

13.0%

7.9%

12.0%

6.1%

9.1%

PPV


96.5%

95.0%

96.3%

95.5%

90.7%

97.5%

97.8%

95.3%

96.1%

95.7%

95.9%

NPV

n 26

n 90

n 25

n 10

n 23

n 10

n 21

n 14

n 17

n 18

n 35

N

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

Sens

79.2%

78.2%

73.6%

84.1%

80%.0

77.6%

65.6%

82.4%

80.4%

77.3%

78.8%

Spec


32.1%

20%.0

30.5%

22.7%

54.8%

13.0%

39.6%

19.2%

28.8%

29.6%

27.8%

PPV

aMajor depressive episode was screened for using the Center for Epidemiological Studies Depression scale (CES-D), post-traumatic stress disorder was screened for using the Harvard Trauma Questionnaire; and alcohol abuse or dependence was screened for using the Alcohol Use Disorders Identification Test (see text). bThe number of individuals speaking other languages was too low to estimate diagnostic test performance.

Total population n 465 Age 33 n 234 Age 33 n 231 Female n 350 Male n 115 Xhosa-speakingb n 309 Afrikaansb n 118 On ART n 224 Not on ART n 241 CD4 200 n 174 CD4 200 n 291

Sens

N

Major depressive episodea

TABLE 4. CHARACTERISTICS OF SCREENING TESTS FOR DEPRESSION, POSTTRAUMATIC STRESS DISORDER AND ALCOHOL ABUSE/DEPENDENCE, OVERALL AND STRATIFIED BY PARTICIPANT CHARACTERISTICS, AMONG FOUR HUNDRED SIXTY-FIVE HIV-INFECTED INDIVIDUALS ENROLLED IN HIV CARE AND TREATMENT SERVICES IN CAPE TOWN, SOUTH AFRICA

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0.00

0.25

Sensitivity 0.50 0.75

1.00

A

0.00

0.25

0.50 1 – Specificity

0.75

1.00

0.75

1.00

Area under ROC curve ⫽ 0.7553

0.00

0.25


1.00

B

0.00

0.25


DISCUSSION


0.00

0.25


1.00

C

0.00

0.25


The overall sensitivity and specificity of the HTQ in detecting MINI-defined PTSD was 38% (95% CI: 33%–42%) and 80% (95% CI: 76%–83%), respectively, when based on the standard 30-item scale analyzed at a cutpoint of 75 to define PTSD (LR 1.8; LR 0.8). The test characteristics were significantly improved among men compared to women (p 0.006). Although the test characteristics of the HTQ in detecting PTSD were suboptimal when the standard cutpoint of 75 was used to define PTSD, the ROC curves for the three tests (Fig. 1) showed that the overall area under the curve for the use of HTQ (0.74) was similar to the measures associated with the use of CES-D (0.76) although lower than that of the AUDIT (0.96). The ROC analysis suggested an optimal cut-off point for the HTQ of approximately 62; when this threshold was used to define PTSD, the test characteristics improved to a sensitivity of 74% and a specificity of 70%. However when the HTQ was recalculated using only the first 16 items (based on DSM-IV criteria for PTSD), the area under the ROC curve did not improve substantially (0.73).

0.75

1.00


FIG. 1. Receiver-Operating-Characteristic curves for the diagnosis of depression (A), posttraumatic stress disorder (PTSD; B), and alcohol dependence/abuse (C) based on brief rating scales, within a sample of 465 HIV-infected individuals enrolled in HIV care and treatment services in Cape Town, South Africa.

These data suggest that there is a substantial burden of mental illness among HIV-infected individuals in primary care settings, and that brief screening checklists can be valid proxy measures for common mental disorders in HIV-infected populations in sub-Saharan Africa. The overall prevalence of MINI-defined mental illness was high in this population, with 19% of participants having either depression, PTSD, or alcohol abuse/dependence. However this prevalence is lower than levels documented in smaller studies of HIV-infected individuals in South Africa, Tanzania and developed country settings.16,30,31 This variability may be due to the use of different methodologies and measures, as most studies have applied brief psychiatric rating scales (often without local validation) rather than more rigorous measures such as the MINI or the Structured Clinical Interview for DSM-IV. It may also be attributable to underlying differences between

MENTAL DISORDERS AMONG HIV-INFECTED INDIVIDUALS

study populations, both between countries and patient populations. In particular, this study focused on a sample of patients attending routine outpatient HIV appointments, who are likely to be in better physical and mental health than a broader sample of HIV-infected individuals who may not be receiving regular medical care. As more data become available on the mental health of HIV-infected individuals in different stages of disease and health care contexts, this possibility warrants further attention. In addition, it is plausible that these differences are simply reflections of different population levels of psychopathology in different regions, though it is difficult to evaluate this possibility given the dearth of populationbased estimates of mental illness in developing countries.32 There may also be a particular interaction between HIV and common mental disorders in some developing countries. This may occur, for example, due to increased stigmatization of HIV disease in many African countries and/or the conditions of widespread poverty, leading to a disproportionate increase in psychopathology among HIV-infected individuals.17,33 Several possible explanations exist for the finding that Afrikaans-speakers were consistently more likely to have MINI-defined depression, PTSD, and alcohol abuse/dependence, even after adjustment for differences in demographic characteristics. First, while interviews were conducted in participants’ home languages we cannot rule out biases due to interviewer conduct, which may have overdetected disorders among Afrikaans speakers and/or underdetected them among Xhosaspeakers. However, interviewers were carefully trained on MINI administration, being mindful of the possible variations in item phrasing and by providing appropriate explanations for different language groups, based on prior research on local language interpretations of psychiatric symptoms.34 More likely is the possibility of systematic differences in participant reporting according to language group. We hypothesize that Afrikaans speakers felt more comfortable discussing psychiatric symptoms compared to Xhosa speakers, due largely to underlying social differences in the expression and weight given to feeling states. This hy-

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pothesis is supported by our previous research in this area34 as well as the finding of an increased sensitivity of each of the brief rating scales in detecting MINI-defined mental disorders among Afrikaans speakers compared to Xhosa speakers. The sensitivity of the AUDIT questionnaire was consistent across all subgroups of the study sample, suggesting that this rating scale has good generalizability across populations. This is in keeping with previous findings from this setting, where we found that individuals from different demographic groups found it easier to respond to questions regarding specific behaviors rather than emotional states.34 The performance of the CES-D was significantly improved among individuals who had CD4 cell counts above 200 cells per microliter, although there were no differences according to participants’ use of ART. We excluded patients with marked cognitive impairment (MMSE scores 24) from the study to limit the variability due to pronounced cognitive impairment. However it is possible that individuals with more advanced HIV disease (and lower CD4 cell counts) who do not meet these exclusion criteria on MMSE may have suffered cognitive impairment which masked their reporting of depressive symptomatology. In addition it is possible that in individuals with more advanced HIV disease, depression is likely to manifest with physical symptoms such as apathy and fatigue which can be more difficult to detect using the CES-D. As other studies have shown that depression appears more common among individuals with lower CD4 cell counts,35 the interaction between HIV disease progression and different forms of mental illness requires additional research. The performance characteristics of the HTQ in detecting PTSD were relatively poor, however, and were not markedly improved by restricting the analysis to items which are based on the DSM-IV definition of PTSD (items 1 to 16). The reasons for the suboptimal performance of the test in this setting are unclear. However, our previous research suggested that the HTQ may not be optimal for assessing PTSD in this population since the items were heavily biased toward emotional experiences, such as detachment and derealization which

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may not be well understood in this setting.31 Moreover, other studies have suggested that a diagnosis of HIV itself can result in PTSD13,35 and the HTQ does not capture this phenomenon adequately. Taken together, these factors may have contributed to an underreporting of symptoms in our study. The issue of cross-cultural translation of both psychiatric concepts and measurement systems is a focus of ongoing debate in South Africa,18,36–38 and the specific issues regarding the measurement of PTSD warrant further attention. This study was limited to patients attending three public sector health facilities in one region of South Africa, and the results may not be readily generalizable to other patient populations across the continent. However, the demographic characteristics of these participants are similar to other samples of HIV-infected individuals seeking health care services in subSaharan Africa, suggesting that these findings may be generalizable to other settings. Also, it is important to note that these psychiatric rating scales are designed primarily for research purposes, where they can be administered, easily and cost effectively, by lay interviewers. The AUDIT’s excellent sensitivity and negative predictive value make it extremely useful in identifying individuals who abuse or are dependent on alcohol and its ease of administration (10 items) make it feasible to use in practice. The CES-D and HTQ are likely to be somewhat less useful as part of routine care, with their positive likelihood ratio estimates suggesting that individuals with the psychiatric disorder in question are only approximately twice as likely to test positive on the respective rating scales, compared to individuals without that disorder. Despite this, these tools may still be useful as an initial screening device in clinical practice to identify individuals who are at high risk of psychopathology and may require further evaluation. In particular, it is important to note that the positive and negative predictive values of these tests will differ when applied to populations with different prevalences of each mental disorder studied. For example, in a population where the prevalence of depression, PTSD, and alcohol dependence/abuse is half that ob-

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served here, the positive/negative predictive values will change to 61%/40%, 44%/57%, and 62%/36%, respectively. Alternatively, in a population where the prevalence of these disorders is twice that observed here, the positive/negative predictive values will change to 58%/43%, 35%/66%, and 58%/42%, respectively. Such changes in predictive values with the prevalence of the disorder under study will occur with any test, and thus sensitivity and specificity (or the likelihood ratios derived from these) are better measures of overall test performance.39 Nonetheless, these variations in predictive values are important to keep in mind when extrapolating these findings to other settings as the prevalence of depression, PTSD and alcohol dependence/abuse is likely to vary across populations. In conclusion, these data indicate that there is a significant burden of mental illness among HIV-infected individuals in this setting. It is important to note that HIV care and treatment services provide a unique opportunity for longitudinal, primary-level mental health care.15 Given the high prevalence of depression, anxiety and substance-related disorders among HIV-infected individuals, there is a clear need for further research into the determinants of mental illness in these populations, as well as simple screening tools which can be used to identify psychopathology in HIV-infected individuals, and ultimately, support the development of strategies to effectively manage these co-morbidities in primary health care settings.

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Address reprint requests to: Dr. Landon Myer Infectious Diseases Epidemiology Unit School of Public Health & Family Medicine University of Cape Town Anzio Road Observatory 7925 Cape Town South Africa E-mail: [email protected]