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AIDS Care
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Prevalence, correlates, and self-management of HIV-related depressive symptoms
L. S. Ellera; E. H. Bunchb; D. J. Wantlanda; C. J. Portilloc; N. R. Reynoldsd; K. M. Nokese; C. L. Colemanf; J. K. Kemppaineng; K. M. Kirkseyh; I. B. Corlessi; M. J. Hamiltonj; P. J. Dolek; P. K. Nicholasl; W. L. Holzemera; Y. -F. Tsaim a College of Nursing, Rutgers The State University of New Jersey, Newark, NJ, USA b University of Oslo, Olso, Norway c School of Nursing, University of California San Francisco, San Francisco, CA, USA d School of Nursing, Yale University, New Haven, CT, USA e Hunter Bellevue School of Nursing, Hunter College, City University of New York, New York, NY, USA f School of Nursing, University of Pennsylvania, Philadelphia, PA, USA g School of Nursing, University of North Carolina, Wilmington, NC, USA h Seton Family of Hospitals, Austin, TX, USA i Graduate Program in Nursing, MGH Institute of Health Professions, Boston, MA, USA j College of Nursing & Health Science, Texas A&M University, Corpus Christi, TX, USA k Greenwich House, New York, NY, USA l Brigham and Women's Hospital, Boston, MA, USA m School of Nursing, Chang Gung University, Toa-Yuan, Taiwan Online publication date: 06 September 2010 To cite this Article Eller, L. S. , Bunch, E. H. , Wantland, D. J. , Portillo, C. J. , Reynolds, N. R. , Nokes, K. M. , Coleman, C.
L. , Kemppainen, J. K. , Kirksey, K. M. , Corless, I. B. , Hamilton, M. J. , Dole, P. J. , Nicholas, P. K. , Holzemer, W. L. and Tsai, Y. -F.(2010) 'Prevalence, correlates, and self-management of HIV-related depressive symptoms', AIDS Care, 22: 9, 1159 — 1170 To link to this Article: DOI: 10.1080/09540121.2010.498860 URL: http://dx.doi.org/10.1080/09540121.2010.498860
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AIDS Care Vol. 22, No. 9, September 2010, 1159 1170
Prevalence, correlates, and self-management of HIV-related depressive symptoms L.S. Ellera*, E.H. Bunchb, D.J. Wantlanda, C.J. Portilloc, N.R. Reynoldsd, K.M. Nokese, C.L. Colemanf, J.K. Kemppaineng, K.M. Kirkseyh, I.B. Corlessi, M.J. Hamiltonj, P.J. Dolek, P.K. Nicholasl, W.L. Holzemera and Y.-F. Tsaim a College of Nursing, Rutgers The State University of New Jersey, 180 University Ave, Newark, NJ 07102, USA; bUniversity of Oslo, Olso, Norway; cSchool of Nursing, University of California San Francisco, San Francisco, CA, USA; dSchool of Nursing, Yale University, New Haven, CT, USA; eHunter Bellevue School of Nursing, Hunter College, City University of New York, New York, NY, USA; fSchool of Nursing, University of Pennsylvania, Philadelphia, PA, USA; gSchool of Nursing, University of North Carolina, Wilmington, NC, USA; hSeton Family of Hospitals, Austin, TX, USA; iGraduate Program in Nursing, MGH Institute of Health Professions, Boston, MA, USA; jCollege of Nursing & Health Science, Texas A&M University, Corpus Christi, TX, USA; kGreenwich House, New York, NY, USA; lBrigham and Women’s Hospital, Boston, MA, USA; mSchool of Nursing, Chang Gung University, Toa-Yuan, Taiwan
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(Received 7 August 2009; final version received 14 May 2010) Depressive symptoms are highly prevalent yet undertreated in people living with HIV/AIDS (PLHAs). As part of a larger study of symptom self-management (N 1217), this study examined the prevalence, correlates, and characteristics (intensity, distress, and impact) of depressive symptoms, and the self-care strategies used to manage those symptoms in PLHAs in five countries. The proportion of respondents from each country in the total sample reporting depressive symptoms in the past week varied and included Colombia (44%), Norway (66%), Puerto Rico (57%), Taiwan (35%), and the USA (56%). Fifty-four percent (n 655) of the total sample reported experiencing depressive symptoms in the past week, with a mean of 4.1 (SD 2.1) days of depression. Mean depression intensity 5.4 (SD 2.7), distressfulness 5.5 (SD 2.86), and impact 5.5 (SD 3.0) were rated on a 1 10 scale. The mean Center for Epidemiologic Studies Depression Scale score for those reporting depressive symptoms was 27 (SD 11; range 3 58), and varied significantly by country. Respondents identified 19 self-care behaviors for depressive symptoms, which fell into six categories: complementary therapies, talking to others, distraction techniques, physical activity, medications, and denial/avoidant coping. The most frequently used strategies varied by country. In the US sample, 33% of the variance in depressive symptoms was predicted by the combination of education, HIV symptoms, psychological and social support, and perceived consequences of HIV disease.
Keywords: depressive symptoms; HIV disease; self-management; symptom management
Introduction In countries in which antiretroviral medications are widely available, HIV/AIDS is a chronic illness requiring management of symptoms caused by the disease or its treatment. Depression is the most common psychiatric diagnosis in people living with HIV/AIDS (PLHAs; Pence, 2009). In our two previous international studies, depressive symptoms were the second most frequently reported, with 56 and 58% prevalence observed (Willard et al., 2009). In the USA, estimated prevalence of depression is 2 10 times higher in PLHAs than in the general population (Bing et al., 2001; Pence, 2009). Conceptualization of depression as major depressive disorder versus depressive symptoms, scales used and dimensions measured may explain differences in reported prevalence. It was suggested that inclusion of somatic
*Corresponding author. Email: eller@rutgers.edu ISSN 0954-0121 print/ISSN 1360-0451 online # 2010 Taylor & Francis DOI: 10.1080/09540121.2010.498860 http://www.informaworld.com
symptoms may inflate estimates, as some symptoms of HIV disease and treatment, such as fatigue, insomnia, difficulty concentrating, and changes in weight and appetite, cannot be distinguished from symptoms of depression (Kalichman, Rompa, & Cage, 2000). However, in some cultures, depression is expressed somatically. In depressed Chinese and North American samples, somatic presentation of depression was more common in the Chinese group, while the North American group reported more psychological symptoms (Ryder et al., 2008). MunËœoz et al. (2005) examined somatic symptoms in depressed patients across Latin America. In Colombia, 82.8% of the sample somatized symptoms of depression. In cross-national studies, differences in the conceptualization and presentation of depression must be considered in its measurement. In the study reported
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here, we conceptualized depression as depressive symptoms, and somatic symptoms are included in our measure. Depressive symptoms in PLHAs are highly prevalent, underreported, and undertreated. While rates of diagnosis and treatment of depression in PLHAs in non-Westernized countries are not available, three US studies reported that up to half of depressed PLHAs receiving care were not diagnosed or treated for depression (Asch et al., 2003; Leserman, 2008; Yun, Maravi, Kobayashi, Barton, & Davidson, 2005). The diagnosis and treatment of depressive symptoms in PLHAs are critical. Depression is associated with poor medication adherence (Ammassari et al., 2004) and risky behaviors, including substance use and unsafe sexual practices (Bing et al., 2001; Brown et al., 2006). Health-related sequelae of depressive symptoms include more rapid disease progression, poorer virologic response to treatment, increased likelihood of immunologic failure, incident AIDSdefining illness, and higher risk of all-cause death (Anastos et al., 2005; Cook et al., 2004; Leserman et al., 2002; Lima et al., 2007). These associations held after controlling for antiretroviral therapy use, medication adherence, substance abuse, clinical indicators, and demographic factors. Predictors of depressive symptoms Depressive symptoms in PLHAs are associated with sociodemographics, social and psychological support, and individuals’ cognitive representations of their illness. Across societies, depression is twice as common in women as in men. Causative factors for this disparity include violence, socioeconomic disadvantage, income inequality, low social status, and responsibility for the care of others (World Health Organization, 2001). Women with HIV/AIDS, particularly those over age 40, are significantly more likely to report depressive symptoms (50% vs. 36%; Clark & Bessinger, 1997). In the general population, rates of depression vary by culture. Prevalence in Colombia is at 10% (Go´mez-Restrepo et al., 2004), Norway at 16.1% (Beiske et al., 2008), Puerto Rico at 12% (Centers for Disease Control, 2009), Taiwan at 1.5% (Ryder et al., 2008), and the USA at 8.8 21.3% (Centers for Disease Control, 2009). Race and ethnicity are associated with depression in PLHA, with higher prevalence among White compared to non-White homeless and marginally housed urban men (Weiser et al., 2006). Other studies link non-White race and Hispanic/Latina ethnicity with higher rates of depres-
sion in HIV-positive women (Anastos et al., 2005; Cook et al., 2002, 2004). Poverty and low educational attainment are associated with depressive symptoms in industrialized and non-industrialized countries (Patel, 2001). Depressive symptoms were greater in urban women, and men who have sex with men (MSMs) with less than high school education and in rural and urban women with low income (Anastos et al., 2005; Hirshfield et al., 2008; Moneyham et al., 2005; Richardson et al., 2001). Social support is inversely associated with mental health in PLHAs (Bajunirwe et al., 2009; Valverde et al., 2007). This has been observed in rural and urban-dwellers, ethnically diverse women with low incomes, injection drug users, and MSMs (Hays, Turner, & Coates, 1992; Moneyham et al., 2005; Prachakul, Grant, & Keltner, 2007; Richardson et al., 2001) Two studies provided empirical evidence of the effect of psychological support on depressive symptoms. Psychoeducational interventions that included psychological support significantly reduced depressive symptoms in PLHAs compared to controls, and within a sample of PLHAs pre- and post-intervention (Pomeroy, Kiam, & Green, 2000; Pomeroy, Rubin, Van Laningham, & Walker, 1997). Illness representation was shown to predict depression in people with chronic illness (Vaughan, Morrison & Miller, 2003). Illness representation of PLHAs in Colombia, Norway, Puerto Rico, Taiwan, and the US showed that the control, timeline, and consequences dimensions of illness representation were significantly associated with frequency and effectiveness of self-care symptom management (Reynolds et al., 2009). Conceptual model The conceptual model for this study combines Leventhal’s common sense model of health threat regulation with empirically derived predictors of depressive symptoms in PLHAs (see Figure 1). According to Leventhal’s model, individuals construct a representation of illness based on symptom experiences, observations, and judgment. Five dimensions include (1) identity (the label and nature of the illness and symptoms); (2) cause (beliefs about cause of the illness); (3) timeline (expected duration and course of the illness); (4) consequences (perceptions about short- and long-term effects of the illness); and (5) control (beliefs about controllability of the illness; Cameron & Leventhal, 2003; Leventhal et al., 1997). These cognitive processes and emotional responses to illness guide symptom self-management.
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Sociodemographics: Age, Gender, Race/ethnicity, Education,
HIV-related Symptoms
Social Support Psychological Support
Depressive Symptoms
Self-Management of Depressive Symptoms
Illness Perception: Timeline Control Identity Consequences
Figure 1. Model for the study.
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Purpose of the study The purposes of this study were to examine (1) prevalence and characteristics (intensity, distress, and impact) of depressive symptoms; (2) self-care strategies used and their effectiveness in symptom management; and (3) the degree to which demographic variables, symptoms, social support, psychological support, and illness representation predicted depressive symptoms. Method Design and settings A descriptive, correlational design was used in this study conducted by the HIV/AIDS International Nursing Research Network (http://www.ucsf.edu/ aidsnursing). A convenience sample of 1217 PLHAs was recruited from community sites providing HIVrelated medical and/or social services in Norway (n 77), Taiwan (n 118), Puerto Rico (n 44), Colombia (n 102), and 14 sites in the USA (n 876). Complete data were available for 1210 participants; 655 respondents reported depressive symptoms during the previous week. Procedure IRB approval was obtained from each site. Following informed consent, instruments were administered. Assistance was provided to respondents as needed. Measures Study instruments were forward and back-translated from English into Chinese, Norwegian, and Spanish to maintain content equivalence. Translated versions were pilot tested (Cha, Kim, & Erlen, 2007).
Demographic Survey A survey booklet was used to collect information on sociodemographic characteristics. The Center for Epidemiologic Studies Depression Scale (CES-D) This 20-item scale was used to measure frequency of depressive symptoms experienced during the previous week (Radloff, 1977). A four level response format includes ‘‘rarely’’ to ‘‘most of the time.’’ Scores range from 0 to 60; scores ]16 suggest clinically significant depressive symptoms. Cronbach’s alpha for the scale was 0.88. The Self-care Activities Checklist This scale included the six most frequently reported symptoms based on our previous studies. Symptom frequency, intensity, distress, and impact were rated on a 1 10 scale. Participants who experienced a symptom during the past week were asked to select self-care activities used and rate the frequency and effectiveness of the activity. Instructions stated ‘‘Here are some things people may do for depression. Please review the list and: (1) circle ‘yes’ if you have tried it or do it now. Circle ‘no’ if you never tried it; (2) if ‘yes,’ how often do you do this? (daily/weekly/ monthly); and (3) does it work? (on a scale of 1 not very well to 10 very well).’’ The Revised Sign and Symptom Checklist for Persons with HIV Disease (SSC-HIVrev) The Revised Sign and Symptom Checklist for Persons with HIV Disease (SSC-HIVrev) consists of 64 items that measure frequency and severity of HIV symptoms (Holzemer, Hudson, Kirksey, Hamilton, &
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Bakken, 2001). Items are rated on a three-point Likert scale with choices of 1 (mild), 2 (moderate), or 3 (severe). Scores include total number of symptoms (range 0 64) and mean severity of symptoms (range 1 3). Cronbach’s alpha was 0.97. The Illness Perception Questionnaire (IPQ) Five Illness Perception Questionnaire (IPQ) scales measure participants’ cognitive representations of HIV: identity, timeline, controllability, consequences, and cause (Weinman, Petrie, Moss-Morris, & Horne, 1996). Identity is measured with list of HIV-related symptoms. Scores range from 0 to 21. Higher scores indicate more symptoms. Timeline, controllability, and consequences are measured using a 34-item Likert scale. Responses range from strongly disagree (1) to strongly agree (5). Each dimension is scored separately. Higher scores on timeline indicate the belief that the illness will last a long time (11 items). Higher scores on controllability indicate the belief that the illness is uncontrollable (12 items). Higher scores on consequences indicate belief in serious short- and long-term illness consequences (11 items). Cause is measured using a 14-item Likert scale, ranging from strongly disagree (1) to strongly agree (5). Subjects rate agreement with each item as a cause of illness. Only identity, timeline, controllability, and consequences were used in analyses. Cronbach’s alphas ranged from 0.61 for timeline dimension to 0.80 for identity. Social support and psychological support Social support and psychological support were each measured with single item scales. Responses ranged from 1 very poor to 10 excellent. Data analysis The Statistical Package for the Social Sciences (SPSS#, Chicago, IL) version 14.0 was used. Analyses were conducted on 655 respondents reporting depressive symptoms the previous week. Descriptive statistics were calculated for demographics, depressive symptoms, and self-care strategies. Hierarchical multiple regression analysis was conducted on the US sample, as other country sample sizes were too small for individual regression analyses. Results The proportion of respondents by country in the total sample (N 1210) reporting depressive symptoms in the past week included Colombia (44%), Norway (66%), Puerto Rico (57%), Taiwan (35%), and the
USA (56%). Fifty-four percent (n 655) of the total sample reported depressive symptoms in the past week. Sociodemographic data are shown in Table 1. Post hoc comparisons revealed significant differences between Taiwan and the USA in depression frequency (p 0.01); between Taiwan and Colombia (p 0.000), Norway (p 0.000), and the USA (p 0.000) in depression intensity and depression distress; and between Taiwan and Colombia (p 0.000), Norway (p 0.018), Puerto Rico (p 0.023), and the USA (p 0.000) in depression impact. The only between-country differences in the Center for Epidemiologic Studies Depression Scale (CES-D) scores were Colombia and the USA (p 0.002). Significant differences between countries were observed in perceived social and psychological support, and IPQ dimensions of identity, controllability, and consequences (see Table 2). Six categories encompassed 19 self-care strategies utilized by respondents: complementary therapies, talking to others, distraction techniques, physical activity, medication use, and denial/avoidant coping (see Table 3). On a 1 10 effectiveness scale, scores of 6 or higher indicate high effectiveness in managing depressive symptoms. Differences in strategies used by country included complementary therapies (x2 115.6, p B0.000), talking with others (x2 60.9, pB0.002), physical activity (x2 21.3, p B0.045), antidepressants (x2 65.5, p B 0.000), and denial/avoidant coping (x2 115.8, p B 0.000). There was no difference in use of distraction techniques. Strategies most frequently used varied by country, however, in some cases only small differences were observed in the top three to five strategies (see Table 3). There were significant gender differences only in the use of complementary strategies (x2 26.4, pB0.000) (see Table 4). In the US sample, depressive symptoms were significantly associated with age (r 0.10, p B 0.033), female gender (r 0.11, p B0.018), income adequacy (r 0.17, p B0.000), education (r 0.18, p 0.000), symptoms (r 0.40, p B0.000), social support (r 0.29, pB0.000), and psychological support (r 0.42, p B0.000). Significant illness perception dimensions included identity (r 0.27, p B0.000), controllability (r 0.14, p B0.002), and consequences (r 0.32, p B0.000). Due to the high rates of physical abuse and forced sexual activity, these two variables were examined. Physical abuse (r 0.19, p B0.000) and forced sexual activity (r 0.15, pB0.000) were significantly related to depressive symptoms. All significant correlates were included in regression analysis. Thirty-three percent
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Table 1. Sociodemographic data (n 655). Variable Age CD4 count (self-report) Viral load (self-report) Time since HIV diagnosis (self-report) Time since AIDS diagnosis (self-report)
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Gender Male Female Transgender Ethnicity Columbia (n 45) African American/Black Hispanic Norway (n 51) African American/Black White Other Puerto Rico (n 25) African American/Black Hispanic White Other Taiwan (n 41) Asian USA (n 493) African American/Black White Hispanic/Latino Asian/Pacific Islander Native American Indian Other Income adequacy Enough Barely adequate Totally inadequate Taking antiretroviral medications Yes No Don’t know HIV risk factors Sex with an HIV man Sex with an HIV woman Shared needles Blood transfusion Don’t know Other Injection drug use Never used injection drugs Former injection drug user Current injection drug user Substance use (past six months) Amphetamines Cocaine Hallucinogens
Range 20 84 years 0 4800 0 750,000 B1 25 years B1 24 years
Mean (SD) 41.3 years (8.6) 431/mm3 (357) 53,308 (132,383) 9.1 years (5.6) 6.4 years (4.4)
Median 41.0 years 380/mm3 3342 8.0 years 5.0 years
Frequency 643 431 167 626 231 428 (65.3%) 218 (33.4%) 7 (1.1%)
1 (2%) 44 (98%) 2 (4%) 47 (92%) 2 (4%) 2 18 3 2
(8%) (72%) (12%) (8%)
41 (100%) 243 114 117 1 13 5
(49%) (23%) (24%) (0.2%) (2.6%) (1%)
117 (18.0%) 334 (51.5%) 198 (30.5%) 455 (69.7%) 196 (30%) 2 (0.3%) 428 135 151 33 65 29
(74.4%) (20.6%) (23.1%) (5%) (9.9%) (6.2%)
401 (61.4%) 219 (34%) 22 (3.4%) 42 (6.4%) 126 (19.2%) 192 (31.6%)
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Table 1 (Continued) Variable
Range
Mean (SD)
Median
Frequency
Heroin Marijuana
34 (5.2%) 146 (22.3%)
Physically abused by partner/other Yes No
299 (47.9%) 325 (52.1%)
Forced sexual activity Yes No
202 (31.2%) 446 (68.8%)
of the variance in depressive symptoms was predicted by the combination of education, HIV symptoms, psychological and social support, and perceived consequences of HIV disease (see Table 5).
findings. Small sample sizes from some sites limited data analyses. The study model is not a comprehensive framework depicting all factors that influence depressive symptoms. These include, but are not limited to, biological and genetic factors, the effects of HIV medications, the virus itself, and stress hormones.
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Limitations
Discussion and conclusion
Study limitations include use of self-report and lack of validation of depressive symptoms. Ethnic groupings were not broad enough to capture culture-specific categories that may have further explained study
More than half of the sample in this study reported experiencing depressive symptoms, with a frequency of more than three days a week across countries.
Table 2. Means, standard deviations, and comparisons of study variables by country (n 655).
CES-D score (0 60 possible range) Depression frequency (Days per week) Depression intensity (1 10 scale) Depression distress (1 10 scale) Depression impact (1 10 scale) Social support (1 10 scale) Psychological support (1 10 scale) HIV symptoms (0 94 score) Illness perception Timeline Consequences Controllability Identity
Colombia (n 45)
Norway (n 51)
Puerto Rico (n 25)
Taiwan (n 41)
USA (n 493)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
22.8 (8.0)
26.5 (12.8)
22.5 (13.4)
24.1 (8.5)
27.8 (11.3)
4.01 4
B0.003 p B0.004
F
df
p
3.4 (2.1)
4.4 (2.2)
3.5 (2.2)
3.3 (1.7)
4.2 (2.1)
x2 15.6
5.6 (2.6)
5.2 (2.4)
5.0 (3.5)
3.3 (1.9)
5.6 (2.7)
28.1
B0.000
6.8 (2.6)
5.3 (2.8)
5.1 (3.5)
3.3 (2.1)
5.6 (2.8)
34.2
B0.000
6.1 (3.2)
5.3 (3.1)
6.0 (3.6)
3.4 (2.3)
5.7 (2.9)
23.5
B0.000
7.2 (2.6)
5.9 (2.7)
7.6 (3.2)
6.9 (2.9)
6.6 (2.6)
57.2
B0.035
6.5 (2.3)
5.5 (2.2)
6.9 (2.6)
6.0 (2.9)
5.9 (2.3)
59.0
B0.026
38.8 (22.5)
43.3 (26.8)
50.6 (30.9)
34.3 (16.7)
48.7 (38.3)
464.3
NS
2.5 (1.7) 2.2 (0.59) 2.0 (0.69) 2.3 (0.87)
117.0 134.7 125.4 39.4
NS B0.000 B0.000 B0.024
2.2 2.4 2.1 2.5
(1.3) (0.57) (0.47) (0.53)
2.7 1.9 2.5 2.0
(1.7) (0.55) (0.50) (0.70)
2.1 2.4 1.8 2.9
(1.7) (0.64) (0.74) (1.1)
2.6 2.2 2.1 2.1
(1.7) (0.49) (0.65) (0.65)
Table 3. Frequency and effectiveness of depressive sym,ptom self-managemnt strategies by country (n 655). Colombia (n 45)
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Strategy
Frequency
Complementary strategies Meditation 3 (7%) Prayer 28 (62%) Talking with others Talk to family/ friends Talk to health care provider Talk to others Attend support group
Medications Antidepressants
Effectiveness rating (1 10), M (SD)
Strategy
Frequency
Puerto Rico (n 25) Effectiveness rating (1 10), M (SD)
Strategy
Frequency
Effectiveness rating (1 10), M (SD)
6.7 (4.5) 9.2 (.97)
Meditation Prayer
Complementary strategies 4 (8%) 7 (14%)
6.2 (3.5) 6.8 (2.1)
Meditation Prayer
Complementary strategies 5 (20%) 22 (88%)
7.6 (2.0) 8.9 (2.2)
26 (58%)
8.1 (2.2)
Talking with others Talk to family/Friends 31 (61%)
5.6 (2.5)
Talking with others Talk to family/friends 21 (84%)
8.8 (1.8)
17 (38%)
8.2 (1.9)
Talk to health care provider 25 (49%)
5.3 (2.5)
Talk to health care provider 16 (64%)
8.1 (2.4)
16 (36%) 19 (42%)
8.1 (1.5) 8.9 (1.3)
Talk to others Attend support group
26 (51%) 5 (10%)
6.2 (2.9) 6.1 (3.1)
Talk to others Attend support group
16 (64%) 10 (40%)
7.7 (2.6) 7.7 (2.6)
(58%) (47%)
8.3 (1.8) 8.0 (1.9)
Distraction techniques Go to work 22 (43%) Treat self with food 24 (47%)
6.5 (2.1) 5.9 (1.9)
Distraction techniques Go to work 10 (40%) Treat self with food 13 (52%)
9.2 (1.3) 8.3 (2.6)
(71%) (7%) (44%) (69%)
8.7 9.0 8.1 8.4
Keep busy Draw Read Listen to music
6.8 6.1 6.0 6.6
Keep busy Draw Read Listen to music
9.1 8.3 9.5 9.6
Distraction techniques Go to work 26 Treat self with 21 food Keep busy 32 Draw 3 Read 20 Listen to music 31 Physical activity Walk
Norway (n 51)
(1.4) (1.0) (1.7) (1.6)
(61%) (2%) (63%) (63%)
(2.0) (3.3) (2.4) (2.3)
6.9 (2.0)
Walk
Medications 5 (10%)
6.6 (3.2)
Antidepressants
7.4 (2.1)
Denial/avoidant coping Avoid negative things 29 (57%)
8.3 (1.5) 8.8 (1.3) 9.0 (1.7) 0
Cigarettes Alcohol Marijuana Street drugs
8.6 (1.3)
Walk
5 (11%)
6.8 (2.7)
Antidepressants
(49%) (7%) (11%) (7%)
20 23 7 4
(39%) (45%) (14%) (8%)
19 3 13 21
(76%) (12%) (52%) (84%)
(2.2) (2.8) (1.3) (1.1)
Physical activity 15 (30%)
9.4 (1.4)
Medications 6 (24%)
9.1 (1.6)
5.0 (2.4)
Denial/avoidant coping Avoid negative things 19 (76%)
9.0 (1.6)
4.0 4.4 5.1 2.6
Cigarettes Alcohol Marijuana Street drugs
(2.8) (2.2) (3.7) (3.0)
12 6 2 1
(48%) (24%) (8%) (4%)
8.2 (2.8) 7.3 (3.3) 9.0 (1.4) 10 (0)
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Physical activity 34 (67%)
19 (42%)
Denial/avoidant coping Avoid negative 22 things Cigarettes 3 Alcohol 5 Marijuana 3 Street drugs 0
31 6 32 32
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Table 3 (Continued) Taiwan (n 41)
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Complementary strategies Meditation Pray
Frequency
0 1(2%)
Effectiveness rating (1 10), M (SD)
Strategy
0 7.0 (0)
Meditate Pray
Frequency
Effectiveness rating (1 10), M (SD)
Complementary strategies 118 (24%) 260 (53%)
7.3 (2.8) 8.2 (2.3)
Talking with others Talk to family/friends Talk to health care provider Talk to others Attend support group
25 17 3 1
(61%) (41%) (7%) (2%)
4.7 5.0 4.3 5.0
(1.4) (1.6) (0.57) (0)
Talking with others Talk to family/friends 293 (59%) Talk to health care provider 256 (52%) Talk to others 201 (41%) Attend support group 137 (28%)
6.8 6.9 6.9 6.6
(2.5) (2.5) (2.5) (2.7)
Distraction techniques Go to work Treat self with foods Keep busy Draw Read Listen to music
19 20 19 2 10 22
(46%) (49%) (46%) (5%) (24%) (54%)
5.3 4.7 4.6 6.5 4.2 4.6
(1.4) (1.9) (1.2) (.7) (1.6) (2.1)
Distraction techniques Go to work 109 (22%) Treat self with foods 190 (39%) Keep busy 267 (54%) Draw 74 (15%) Read 194 (39%) Listen to music 293 (59%)
6.7 6.9 7.1 7.0 7.2 7.6
(2.7) (2.5) (2.4) (3.0) (2.5) (2.4)
Physical activity Walk
21 (51%)
Medications Antidepressants Denial/avoidant coping Avoid negative things Cigarettes Alcohol Marijuana Street drugs
1 (2%) 16 (39%) 0 0 0 0
Physical activity 277 (56%)
7.2 (2.4)
Medications 177 (36%)
6.8 (2.7)
4.0 (1.7)
Walk
5.0 (0)
Antidepressants
4.7 (1.6) 0 0 0 0
Denial/avoidant coping Avoid negative things 258 (52%) Cigarettes 189 (38%) Alcohol 107 (22%) Marijuana 97 (20%) Street drugs 47 (10%)
6.9 5.7 4.8 6.0 4.1
(2.5) (3.0) (2.8) (3.2) (3.2)
L.S. Eller et al.
Strategy
USA (n 493)
AIDS Care
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Table 4. Frequency and effectiveness of depressive symptom self-management strategies by gender (n 655). Female (n 218) Frequency
Effectiveness rating (1 10), M (SD)
Frequency
Effectiveness rating (1 10), M (SD)
44 (20%) 139 (64%)
7.5 (2.8) 8.2 (2.5)
99 (23%) 197 (46%)
7.2 (2.7) 8.4 (1.9)
141 (65%)
6.9 (2.6)
276 (65%)
6.7 (2.4)
117 (54%)
7.0 (2.7)
243 (57%)
6.7 (2.4)
109 (50%) 69 (32%)
7.0 (2.7) 6.5 (2.8)
178 (42%) 126 (29%)
7.0 (2.5) 7.1 (2.6)
Distraction techniques Go to work Treat self with food Keep busy Draw Read Listen to music
66 101 139 37 108 145
6.7 7.2 7.2 7.0 7.6 7.5
135 190 263 65 190 285
6.9 6.6 7.2 7.0 6.9 7.6
Physical activity Walk
118 (54%)
7.2 (2.5)
271 (63%)
7.1 (2.4)
74 (34%)
6.7 (3.1)
136 (32%)
7.0 (2.5)
129 (59%)
6.9 (2.7)
239 (56%)
6.8 (2.4)
5.9 4.8 5.3 4.6
176 118 91 46
5.6 5.1 6.5 2.6
Strategy Complementary strategies Meditation Prayer Talking with others Talk to family/ friends Talk to health care provider Talk to others Attend support group
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Male (n 428)
Medications Antidepressants Denial/avoidant coping Avoid negative things Cigarettes Alcohol Marijuana Street drugs
74 39 29 18
(30%) (46%) (64%) (17%) (50%) (67%)
(34%) (18%) (13%) (8%)
(2.5) (2.4) (2.5) (3.0) (2.3) (2.5)
(3.2) (3.1) (3.4) (3.8)
Observed differences between Taiwan and other countries in frequency of depression is in keeping with other studies reporting prevalence rates of 1.5% in Taiwan vs. 2.9 19% in other countries (Ryder et al., 2008; Weissman et al., 1996). We also found that intensity, distress, and impact of depression in
(32%) (44%) (61%) (15%) (44%) (67%)
(41%) (28%) (21%) (11%)
(2.6) (2.5) (2.4) (2.9) (2.6) (2.4)
(3.0) (2.7) (3.1) (2.9)
the Taiwan subsample were lower, suggesting that the perceived experience of depression also differs in this culture. Despite differences, depressive symptoms clearly had an effect on respondents’ lives regardless of country, suggesting that clinicians routinely assess PLHAs for depressive symptoms. A brief scale
Table 5. Summary of hierarchical regression analysis for predictors of depressive symptoms in the US sample (N 493). Criterion
Predictor
Depression
Demographics Education HIV symptoms Support Psychological support Social support Illness representation Consequences
b
p
0.17 0.19
0.000 0.000
0.24 0.11
0.000 0.036
0.18
0.002
R2 change
Adj. R2
0.08 0.10 0.12
0.18 0.31
0.04
0.33
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L.S. Eller et al.
such as the CES-D, validated in several languages, can readily be used in clinical settings. Once the presence of depressive symptoms is established, interventions, including self-care strategies, can be employed. Clark, Gong, and Kaciroti (2001) suggest that self-care is central to symptom management, and patients should be provided with a range of self-management alternatives to maximize symptom control. Participants reported the use and effectiveness of several self-management strategies, which varied by country. In the Colombian sample, most strategies, except antidepressants, avoid negative things and meditation, were rated very effective (greater than 8.0). Distraction techniques were most frequently used. In the Norway sample, distraction techniques and walking were most frequently used; however, effectiveness ratings were lower overall. In the Puerto Rico sample, prayer, talking to family and friends and listening to music were each used by more than 80% of respondents, and had very high effectiveness ratings. In the Taiwan sample, complementary strategies were used by only one respondent, the only denial/avoidant coping strategy used was avoiding negative things, and effectiveness ratings of all strategies were low. It may be that self-care is not generally used, or it may be that culturally relevant self-care strategies were lacking for this group. In the US sample, more than half of respondents used one or more strategies in each category except for antidepressants, used by 36% of the sample. Effectiveness ratings were above 6.0 for all strategies except alcohol and street drug use. Cultural differences in strategies employed and perceived effectiveness suggest that additional international studies are needed with larger samples before clinicians can recommend self-care strategies tailored to the unique needs and preferences of their patients. Between 2 and 36% of participants, all of whom reported depressive symptoms, were on antidepressants. It may be that PLHAs are not being screened, medications are not available, or there are negative cultural beliefs regarding mental illness and its treatment (Yip, 2005). The use of addictive substances for self-care was relatively low in all groups, and they were not reported as highly effective. Use of alcohol was highest in Norway, cigarettes highest in Puerto Rico, and street drugs and marijuana highest in the USA. No addictive substance use was reported in the Taiwan sample. The mechanisms that underlie the effectiveness of self-care strategies on depressive symptoms are unclear, and require further research. However, knowledge of effective self-management strategies,
based on the experiences of PLHAs, may enable clinicians to reduce the impact of depressive symptoms. Contracting with clinicians may be one method by which patients can select specific self-care behaviors they view as desirable and achievable for symptom management. Contracting was effective in changing health behaviors and was the most helpful component in an intervention for self-management of HIV/AIDS (Gifford & Sengupta, 1999). In addition to self-management strategies, observed predictors of depressive symptoms suggest additional points of intervention for clinicians in the USA. These require validation in studies with larger international samples. Low educational attainment predicted greater depressive symptoms. Patients with more education may have better access to or comprehension of information, enabling them to better manage HIV disease. Clinicians should assess patients’ educational level, provide appropriate information, and assess their understanding. Psychological and social support predicted depressive symptoms. Clinicians can provide psychological support and referrals for counseling and support groups. Patients can be assisted in identifying individuals who could provide support and can roleplay behaviors that can result in supportive interactions. Specific support-seeking and support-receiving behaviors used with friends, partners, and parents can be successful in increasing social support for PLHAs (Derlega, Winstead, Oldfield, & Barbee, 2003). Three types of social support described in interviews with PLHAs were emotional support (feeling validated, accepted, and valued), informational support (facts regarding HIV and communication skills), and appraisal support (understanding HIV as a controllable chronic disease rather than a prematurely lethal one) (Mitchell et al., 2007). Clinicians routinely provide emotional and informational support in interactions with patients. In addition, clinicians could provide PLHAs with appraisal support, altering perceived consequences of HIV, another predictor of depressive symptoms. Targeted information and counseling can change patients’ perception of HIV disease to that of a manageable chronic disease. Symptom management for depression in people with HIV disease is crucial. Depressive symptoms are associated with risky behaviors, non-adherence, immune dysregulation, and poorer disease outcomes. This study validated the use of previously identified self-care strategies for management of depression in PLHAs in five countries. Findings suggest that selfcare strategies can be taught to and will be used by PLHAs, and they are effective in reducing depressive
AIDS Care symptoms. Longitudinal studies with sufficiently large sample sizes are needed to examine the impact of self-care strategies on depressive symptoms and on the behavioral and clinical outcomes linked to those symptoms.
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