Abstract
Background
Depressive symptoms are highly prevalent among people living with HIV (PLWH). We leveraged Latent Profile Analysis (LPA) to identify profiles of depressive symptoms among PLWHs. We also investigated differences in psychological factors of interest, demographic characteristics, and HIV-related factors across patients’ profiles.
Methods
A cross-sectional study was conducted at one hospital and two designated prison facilities in Hunan province, China. A total sample of 533 PLWHs (320 recruited from the hospital, 213 recruited from prisons) completed the survey. Depressive symptoms were assessed using the 9-item Patient Health Questionnaire (PHQ-9). Family function, resilience, childhood trauma, demographic characteristics, and HIV-related factors were also evaluated. We conducted LPA and multinomial logistic regression analyses to: 1) identify distinct profiles for depressive symptoms; 2) identify demographic characteristics, and HIV-related, and psychological factors predicting PLWHs’ likelihood to express a specific profile.
Results
We identified three distinct profiles of depressive symptoms among PLWHs: severe symptoms (11.8%), moderate symptoms (40.5%), and low/no symptoms (47.7%). Moderate/ severe family dysfunction, low resilience, experiencing emotional abuse and neglect were more likely to fall in the “severe symptoms” rather than the “low/no symptoms” profile. In addition, severe family dysfunction, low resilience, and experiencing emotional neglect indicated a higher likelihood of being classified in the “moderate symptoms” profile, compared to the “low/no symptoms” profile.
Conclusion
Identifying profiles of depressive symptoms among PLWHs using the PHQ-9 items allows for understanding of the distinct paths of development of depressive symptoms and for develo** tailored prevention and intervention programs for PLWHs.
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Background
As is evident, depression is the most common mental disorder among people living with HIV/AIDs (PLWH), the prevalence of which is estimated to be two to four times higher than in general population [1, 2]. For instance, Wang and colleagues reported that prevalence of clinical depression or depressive symptoms (which do not necessarily meet the entire diagnostic criteria for a depressive disorder) in general PLWH to be approximately 50.8% in China [3]. Meanwhile, depressive symptoms have been identified as a risk factor against broader health outcomes among the PLWH, such as reducing one’s antiretroviral therapy adherence, increasing HIV viral loads and lowering CD4 counts [4, 5], which result in impaired immunological response and even heightened mortality [6, 7]. As such, screening for depressive symptoms addresses an overriding concern in identifying risk factors for adverse health outcomes among PLWHs.
Although depressive symptoms have been widely reported in PLWHs around the world, most studies are based on variable-oriented approaches that fail to reveal different patterns between individuals and may therefore draw over-generalized conclusions based on overall samples [8]. In contrast, person-oriented approaches capture information at the individual level, allowing for a more fine-grained understanding of symptom presentations, ideal for psychopathology research [9]. The uses of person-oriented approaches, such as latent class analysis (LCA), latent profile analysis (LPA), to explore the structure of psychopathology have become increasingly popular over the past decade. LPA is a type of LCA that uses continuous indicators of symptom severity rather than binary indicators (i.e., symptom absence or presence [10]), which can provide assessment of symptom profiles with greater granularity.
In recent years, a growing number of studies employed LPA to explore the profiles of depressive symptoms in clinical [11, 12] and non-clinical samples [13, 14]. For instance, Saracino et al. (2020) identified a four-class solution among patients with cancer, which were termed as the “no/low symptoms” group, “mild depressive symptoms” group, “patterned response” group, and “moderate depressive symptoms” group [11]. Moussavi et al. (2021) applied LPA to discern heterogeneous patterns of anxiety and depressive symptoms among youth in foster care, and confirmed the presence of three subtypes: low, medium, and high symptom profile [15]. However, the heterogeneity of depressive symptoms among PLWHs has only been scarcely studied.
Collectively, we carried out a mental health screening survey for PLWHs in Hunan province in China with the support of the local government, which offered an opportunity to explore the heterogeneity of depressive symptoms among PLWHs, using LPA. Much literature suggests that individual characteristics (e.g., sex [16], resilience [17]), environmental factors (e.g., family function [18]), and previous life events (e.g., childhood trauma [19]) all have significant effects on depressive symptoms. Thus, the present study aimed to further explore whether relevant factors (e.g., socio-demographics, family function, resilience, and childhood trauma) are significant predictors of distinct profiles of depressive symptoms in PLWHs. Based on previous work, we speculated that LPA would identify several different depressive symptom profiles among PLWHs (Hypothesis 1). We also anticipated that resilience, family function, and childhood trauma were significant predictors of distinct profiles for depressive symptoms (Hypothesis 2).
Materials and method
Participants and procedure
The participants were 533 PLWHs from one hospital and two designated prison facilities in Hunan, China. A convenience sample of 320 PLWHs who regularly visit the hospital was recruited from HIV/AIDS clinic of the First Hospital of Changsha (Sampling time: from March 2019 to June 2019), and the participants were all outpatients. Meanwhile, in August to September 2019, a cluster sampling of participants from two prisons dedicated to the incarceration of HIV-infected prisoners was conducted, and data from a total of 213 valid samples were obtained. The survey was conducted voluntarily and anonymously, and all participants (or their caregivers, if age < 18) signed an informed consent form before starting the survey. Participants can withdraw from the study at any time if they feel uncomfortable. Detailed sampling and data collection have been described in elsewhere [20].
This study was carried out in accordance with the Helsinki Declaration as revised 1989 and approved by the Ethics Committees of ** with stressor [51, 52], thereby reduced individual’ depressive symptoms. Meanwhile, low resilience seemed to be the strongest predictive factor for development of depressive symptoms. Resilience, as a dynamic course and drives a person to grow in the face of adversity [53]. Resilience is proposed as a potential factor to ameliorate negative emotions and help maintain well-being [54]. Our results also indicate the possible impact of childhood trauma on the development of depressive symptoms among PLWHs. Specifically, emotional abuse and neglect, but not sexual abuse, physical abuse and neglect are predictive of depressive symptoms in PLWHs. Our findings fit with previous results suggesting childhood emotional trauma plays a more important role in depression than other types of childhood trauma [55, 56]. As reported in previous studies [57, 58], emotional abuse is associated with emotion dysregulation, while emotional neglect is associated with deficiency in adaptive emotion regulation. Furthermore, based on social learning theory, individuals who are emotionally neglected may not be able to learn adaptive emotion regulation strategies through caregiver modeling, which predisposes them to depression in adulthood [59].
Our findings suggest that therapeutic interventions targeting depressive symptoms may benefit from a tailored approach that considers individual symptom patterns of depression. For example, PLWHs in profile 1 (severe symptoms) have severe overall symptoms and therefore require prompt clinical treatment to help restore good emotional functioning. Meanwhile, mild/moderate depressive symptoms were present in PLWH in profile 2 (moderate symptoms), with sleep disturbances being the most prominent. Therefore, interventions can be carried out to address sleep problems (e.g., cognitive behavioral therapy [60], mindfulness-based interventions [61]), with the aims to improve not only sleep problems but in turn enhance PLWHs’ mood. Moreover, influential factors should also be taken into consideration for effective psychosocial intervention for PLWHs. Empirical studies have shown the effectiveness of multiple family therapies in improvement in family function, and thereby amelioration of depressive symptoms [62]. Starting from resilience or trauma may be an effective way to protect mental health of HIV/AIDs patients, such as the Improving AIDS Care after Trauma (ImpACT) [63] and Resiliency-based intervention [64].
Despite all the relevant findings, several limitations of the current study should be noted. First, our measures of depressive symptoms and other psychological factors relied on self-report questionnaires, which might be influenced by reporting bias caused by recollection inaccuracy and individuals’ own psychiatric states. Meanwhile, although the internal consistency of PHQ-9 in the current sample was high (α = 0.92), the validity of the Chinese version of PHQ-9 in PLWHs has not been fully tested and therefore needs to be interpreted with caution. Second, the data were collected in only one province of China, which is uncertain whether our findings could be generalized to all PLWHs to other regions of China. Thus, future studies would benefit from examining depressive symptoms in samples that are more representative of the PLWH in China. Third, some confounding factors associated with PLWHs’ depressive symptoms were not considered, such as HIV-related stigma [65]. Finally, PLWH sample of this study was composed of two separate groups, namely outpatients and prisoners. Significant differences in some of the socio-demographic characteristics and HIV-related factors (e.g., age, sex, duration of HIV infection) found to exist between these two groups in the previous study [20]. In addition, the prisoners included in this study were incarcerated in specific prisons, and social isolation may have a potential impact on the patients’ depressive symptoms. Therefore, results need to be interpreted with caution.
Conclusion
In summary, we provide evidence of distinct profiles for depressive symptoms in a sample of Chinese PLWHs, which were defined as the “severe symptoms”, “moderate symptoms”, and “low/no symptoms”, respectively. Family function and resilience served as strong protective factors against depressive symptoms, while childhood trauma, especially emotional abuse and neglect contributed as risk factors. These factors should also be taken into consideration for effective psychosocial intervention for PLWHs.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author (Xuan Ouyang: ouyangxuan@csu.edu.cn) on reasonable request.
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Acknowledgements
The authors would like to show their great gratitude to all participants and related workers in this study for their participation.
Funding
This work was supported by the ogarty Center Project of NIH (D43 TW 009579), the China Precision Medicine Initiative (2016YFC0906300), and the National Natural Science Foundation of China (81671335, 81701325, 81801353, 82071506).
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DW contributed significantly to acquisition and interpretation of data, drafting and revising of the manuscript for publication. QD and HC were significantly involved in the conception, design, and analysis of the data. MW, ZL, and HW contributed to the drafting and revision of the manuscript and gave final approval to its publication. XOY was significantly involved in the conception and design of the study as well as the revision of the manuscript and final approval of its publication. The author(s) read and approved the final manuscript.
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Wang, D., Deng, Q., Chen, H. et al. Profiles of depressive symptoms and influential factors among people living with HIV in China. BMC Public Health 23, 151 (2023). https://doi.org/10.1186/s12889-023-15057-4
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DOI: https://doi.org/10.1186/s12889-023-15057-4