Among all 1560 participants, 405 (26%) reported history of lifetime suicidal ideation, plan or attempt. Among individuals who endorsed depressive symptoms on the CIDI, the rate of lifetime suicidal ideation, plan or attempt was 41.3%. Moreover, longitudinal analysis revealed that 5% of those with at least one follow-up visit reported incident or worsening of suicidal ideation or behavior, and that this incident worsening was associated with more depressive symptoms. These findings emphasize the importance of thorough suicide evaluations among HIV-infected cohorts.
Whereas some studies have shown the rate of ideation to be elevated in HIV+ cohorts in comparison to HIV− controls, consistent rates have not been established. The prevalence rate of suicidal ideation found in this study (26%) was higher than the rate reported by Carrico and colleagues (19.3%)(Carrico et al., 2007
) and lower than that found in another study 31% (Sherr et al., 2008
). Of note, however, is that both of these studies assessed the 1-week prevalence of suicidal ideation rather than the lifetime prevalence assessed in the current study. In a much smaller HIV+ cohort, Robertson and colleagues reported a lifetime suicidal ideation prevalence rate of 56% (Robertson et al., 2006
The lifetime prevalence of suicide attempt in the CHARTER cohort was approximately 13%. This is lower than the approximate rate of 20% reported in previous studies of HIV+ individuals conducted in the United States during the pre-cART era (Kelly et al., 1998
, Robertson et al., 2006
). Additionally, a 2008 investigation conducted in France yielded a lifetime suicide attempt prevalence of 22% in a large HIV+ cohort (Preau et al., 2008
This study confirmed previous studies indicating a lack of relationship between suicide attempt and estimated duration of HIV illness. This is consistent with previous research that has suggested that HIV+ individuals may develop healthy and effective coping strategies over the course of HIV illness (Cooperman and Simoni, 2005
, Robertson et al., 2006
). We also found that Black ethnicity was a significantly associated with more severe lifetime suicide behavior, a finding that is in agreement with results from previous studies (Sherr et al., 2008
). This finding may indicate that the stigma and shame associated with HIV infection increases the risk for mood disturbances in this population. For instance, factors such as social support and effective coping strategies are likely more important to successfully avoiding suicidal thoughts and behavior than the duration of HIV infection.
Individuals with a history of suicidal ideation and suicide attempt reported significantly higher levels of current depressive symptoms and had a significantly higher prevalence of current (within the last 30 days) major depressive disorder, as well as higher levels of plasma HIV RNA. Higher levels of plasma HIV RNA may indicate decreased adherence to ARV medications in currently depressed individuals. Participants who attempted suicide were also significantly more likely to report a lifetime history of substance use disorder (abuse or dependence), and to be currently taking psychotropic medications. Although currently depressed participants may have been more likely to report past behaviors, it is unlikely that this accounted for the significant association that was observed. The fact that prior suicidal ideation and behavior is associated with current depression in this population indicates that these individuals may still be at risk for future suicidal ideation and behavior. Those who had attempted suicide were significantly less likely to be on an efavirenz-containing ARV regimen; this is likely a result of provider bias in not prescribing efavirenz to persons with significant psychiatric problems. Clinicians should be cognizant of past suicidal ideation or behavior in their patients, and monitor them carefully for current mood disturbances.
This study also had a number of important limitations. First, suicide and other psychological data were based on participant self-report. Because of possible stigma associated with report of psychological symptoms, some participants may not have admitted to suicidal ideation or attempt; inaccurate responses with regard to suicide questions would lead to misclassification of subjects into the wrong suicide category, possibly causing an underestimation of the prevalence of suicidal ideation and attempt in the CHARTER cohort. It should be noted, however, that self-report methodology is a limitation of most studies of this nature. The present study focused on lifetime rates of suicidal thoughts and behavior rather than current suicide reports. Because of the focus on past behavior, and the fact that the data were gathered in the context of a larger study on the neurocognitive consequences of HIV infection, data was not collected on the timing of ideation or attempt (e.g., before or after HIV diagnosis), frequency (e.g., frequency of ideation or number of attempts), or nature of suicide attempt (e.g., passive versus active attempt, in the context of a major depressive episode). Moreover, no measures of social support were available for consideration. Previous studies of suicide in the context of HIV infection have consistently shown social support and stability to be protective against suicidal ideation and attempt (Carrico et al., 2007
, Sherr et al., 2008
Although the suicidal ideation and attempt may or may not have occurred in the context of HIV illness, these individuals still bear a heavy psychological burden. Physicians treating HIV+ individuals should be aware of the higher prevalence of major depressive disorder, as well as the high likelihood that many of their patients may have struggled with suicidal ideation or attempt in the past. In recognizing the increased prevalence of psychological disturbance in this population, clinicians may be better able to address the enduring burden of past suicidal thoughts or behavior.
Although additional longitudinal studies are needed to confirm these findings, results from this study may assist in identifying individuals who may be at increased risk for psychological distress. In the future, longitudinal analysis of the correlates of incident suicidal ideation and suicide attempt in the context of progressing HIV illness are needed. Knowledge of when suicidal ideation and attempts occurred during the participants' lifetime would allow a more complete understanding of mood disturbance in the context of HIV infection. Additionally, future studies should take measures of social support into account in order to provide better understanding of suicidal ideation and behavior in this population.