People living with HIV
HIV infection and mental health: suicidal behaviour—systematic review
Catalan J, Harding R, Sibley E, Clucas C, Croome N, Sherr L. Psychol Health Med. 2011 Oct;16(5):588-611.
Suicide has long been associated with serious illness generally and HIV specifically. New treatments have affected prognosis in HIV positively, but it is unclear how they affect suicidal burden (thoughts, self-harm and completions). This review examines all published suicide and HIV data for a definitive account of (1) prevalence of HIV-related suicidality, (2) measurement within studies and (3) effectiveness of interventions. Standard systematic research methods were used to gather quality published papers on HIV and suicide, searching published databases according to quality inclusion criteria. From the search, 332 papers were generated and hand searched resulting in 66 studies for analysis. Of these, 75% were American/European, but there was representation from developing countries. The breakdown of papers provided 12, which measured completed suicides (death records), five reporting suicide as a cause of attrition. Deliberate self-harm was measured in 21, using 22 instruments; 16 studies measured suicidal ideation using 14 instruments, suicidal thoughts were measured in 17, using 15 instruments. Navigating the diverse range of studies clearly points to a high-suicidal burden among people with HIV. The overview shows that autopsy studies reveal 9.4% of deceased HIV+ individuals had committed suicide; 2.4% HIV+ study participants commit suicide; approximately 20% of HIV+ people studied had deliberately harmed themselves; 26.9% reported suicidal ideation, 28.5% during the past week and 6.5% reported ideation as a side effect to medication; 22.2% had a suicide plan; 19.7% were generally “suicidal” (11.7% of people with AIDS, 15.3% at other stages of HIV); 23.1% reported thoughts of ending their own life; and 14.4% expressed a desire for death. Only three studies recruited over 70% female participants (39 studies recruited over 70% men), and six focussed on people who inject drugs. Only three studies looked at interventions – predominantly indirect. Catalan and colleagues’ detailed data suggest that all aspects of suicide are elevated and urgently require routine monitoring and tracking as a standard component of clinical care. There is scant evidence of direct interventions to reduce any aspect of suicidality, which needs urgent redress.
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Editor’s note: This systematic review of suicidality among people living with HIV found clear gaps in the research database. Only 25% of the studies were from outside the USA, Canada, and Western Europe and only 1% were from sub-Saharan Africa, the region most affected by HIV. Further, there are no standardised definitions of suicidal ideation, suicidal thoughts, and deliberate self-harm, and a wide range of study instruments exists, making it impossible to pool data or compare findings from different studies. What is clear from the literature is that people living with HIV experience higher levels of suicidality, both before and after HIV diagnosis, and the direction of the relationship between HIV serostatus and suicidality is unclear, meaning that we don’t have good evidence to show us which comes first. Further, it is unclear whether the advent of effective antiretroviral therapy has influenced levels of suicidality. More research in low- and middle-income countries and more studies of women are urgently needed. From a direct prevention perspective, health care providers should assess for the presence of suicidal thoughts, active plans, and acts of deliberate self-harm in patients living with or at risk for HIV infection. Critically, there is a striking dearth of information on strategies to reduce suicidality among people living with HIV, an area of obvious concern.
