Hopelessness, Depression and Suicidal Ideation in HIV-Positive Persons
Govender, R. D., Schlebusch, L., South African Journal of Psychiatry
While suicidal ideation has been extensively studied in the general and medical population, (1,2) its relationship with HIV infection is less well documented. This is of concern, since the psychological responses to an HIV-positive result can be wide ranging and include feelings of hopelessness, helplessness, anxiety, worthlessness and depression and suicidal behaviour. (3-5) Recognising this in a biopsychosocial context is paramount to understanding the relationship between the HIV/AIDS pandemic and the increased prevalence of suicidal behaviour in South Africa. (4,5) The association between hopelessness, depression and suicide has been well documented. (1,5) Hopelessness, being a feeling of despair and extreme pessimism about the future, forms part of Beck's 'cognitive triad' (6) and cognitive theory of depression. (7) Central to depression are negative thoughts generated by dysfunctional beliefs, (7) which in part may trigger suicidal behaviour in HIV-positive patients. (5)
Depression has been identified as a high-risk factor for suicidal behaviour, and a significant percentage of all depressed persons may die by suicide. The lifetime risk for suicide in the general South African population has been found to be about 17%. (5-10) Likewise, studies in Africa have reported high rates of depressive symptoms and suicidal behaviour in HIV-infected persons, (5,11,12) with the lifetime prevalence for depression ranging from 22% to 45% in this population. (13) The prevalence of depression has been reported to be almost twice as high in HIV-positive than in HIV-negative persons. (13) Nevertheless, HIV-related suicidal behaviour is a complex phenomenon (4-5,14-15) that requires further research. It is against this backdrop that the present study aimed to explore the relationship between hopelessness, depression and suicidal ideation in a patient cohort recently diagnosed as HIV positive.
The sample comprised 156 HIV-positive patients assessed 72 hours after diagnosis, and 109 seropositive patients assessed at 6 weeks' follow-up. This sample was obtained from patients attending the voluntary counselling and testing (VCT) HIV clinic at a university-affiliated state hospital in Durban, South Africa. The study was conducted over a 3-month period. The recruited patients voluntarily signed informed consent and were advised not to answer questions they considered intrusive or sensitive. Patients who tested HIV negative were excluded from the analyses for purposes of this study. The study was approved by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal, and permission to conduct it was granted by the relevant health institution.
The Beck Hopelessness Scale (BHS) and the Beck Depression Inventory (BDI) were used in the study. They were considered appropriate given that they were developed by Beck within the context of his cognitive theory of depression, and their excellent internal consistency, reliability and concurrent validity have been well established across a wide variety of samples. The BHS is designed to measure negative expectations and feelings of hopelessness about the future and has been used in both inpatients (1) and outpatients. (16) Feelings of hopelessness play a pivotal role in the development of negative cognitions, leading to the belief that suicide is the only option to escape unbearable psychological pain. (5,17-18) According to the results from empirical studies, elevated scores on the BHS are significantly related to suicidal ideation, which can be used to predict eventual suicidal behaviour. (1,16-17) The scale consists of items that are endorsed as either true or false, with 9 of the items keyed false and 11 keyed as true. The answers are totalled to obtain a hopelessness score ranging from 0 to 20. (16) As in other research, (1,16) in this study we used a cut-off score of 9 and above on the BHS to identify suicidal ideation in the HIV-infected patients studied. …