The rates of current suicidal ideation among HIV-positive individuals are markedly elevated [1,2], even in comparison with lifetime prevalence estimates for the general population . Although differences in suicidal ideation between HIV-positive and HIV-negative peers have not been reliably observed [4,5], investigations in the era before antiretroviral therapy (ART) determined that HIV-positive individuals are more likely to commit suicide [6–8]. As a result, contemporary studies have examined correlates of suicidal ideation among HIV-positive individuals to assist clinicians with identifying those who may be at the greatest risk.
Because there is great diversity among HIV-positive individuals, demographic characteristics may assist with differentiating subgroups at increased risk of suicidal ideation. Consistent with some findings from the general population [9,10], white and gay-identified HIV-positive individuals report higher rates of suicidal ideation . Although it is unclear if there are sex differences in suicidal ideation among HIV-positive individuals , women may be more likely to attempt suicide . There are also aspects related to living with a chronic, debilitating illness such as managing HIV symptoms and other stressors related to the emergence of AIDS that predict suicidal ideation [2,5,12]. In the ART era, managing burdensome medication side effects has been associated with a poor quality of life [13,14], and decrements in immune status predict subsequent elevations in distress . Consequently, more severe side effects of ART, detectable HIV viral load, and a critically low T-helper (CD4) cell counts may also be related to suicidal ideation. Elevated distress associated with illness-related burdens may be further compounded by co-morbid affective or substance use disorders, which are common among HIV-positive individuals . In fact, a variety of psychosocial and behavioral factors such as perceived stigma, social isolation, distress, lower levels of coping self-efficacy, avoidant-oriented coping, alcohol and substance use, and concern about transmitting HIV are associated with suicide ideation [1,2,17].
Although informative, previous studies have focused almost exclusively on HIV-positive men who have sex with men, and have examined factors associated with suicidal ideation in small samples . We examined the rates and correlates of suicidal ideation in a diverse sample of 2909 HIV-positive individuals. By testing a comprehensive model, we examined whether demographic characteristics, illness-related burdens, alcohol and substance use, and psychosocial factors are independently associated with suicidal ideation.
HIV-positive individuals in four US cities (San Francisco, Los Angeles, Milwaukee, and New York City) were screened between July 2000 and January 2002 for a randomized behavioral prevention trial . Participants completed an informed consent and provided documentation of their HIV-positive serostatus. Assessments were conducted using computer-assisted interviewing methods to enhance the veracity of self-reports of sensitive issues such as suicidal ideation . Study team members further evaluated participants who reported intent of self harm.
Age, race/ethnicity, gender, education, sexual orientation, relationship status, stability of living situation, and time since HIV diagnosis were assessed by questionnaire.
Self-reported HIV viral loads and CD4 cell counts were assessed. Previous investigations have supported the validity of self-reported immune measures , and self-report may be more strongly related to suicidal ideation. Participants also rated from 1 (it doesn’t bother me at all) to 4 (it bothers me a great deal) the severity of 25 HIV symptoms (e.g. fevers) or ART side effects (e.g. diarrhea) during the past 3 months . Higher composite scores indicate greater severity (Cronbach's α = 0.92).
Alcohol and substance use
We assessed the use of alcohol and illicit substances in the past 3 months. Alcohol and substance use were rated from 1 (never) to 9 (more than once a day). We also examined whether participants reported injecting any substances during the past year.
Perceived social support
The 24-item Social Provisions Scale  assesses perceived social support. Items are rated from 1 (strongly disagree) to 4 (strongly agree). Higher composite scores indicate greater social support (Cronbach's α = 0.82).
Coping self-efficacy was assessed with an abbreviated (15-item) version of a 26-item scale [22,23]. Participants rated from 0 (cannot do at all) to 10 (certain can do) the extent to which they believe they could perform behaviors important to adaptive coping. Higher composite scores indicate greater coping self-efficacy (Cronbach's α = 0.92).
Depressive symptoms and suicidal ideation
The 21-item Beck Depression Inventory (BDI) assesses depressive symptoms during the past week . Items are rated from 0 (absent) to 3 (severe). One BDI item assesses suicidal ideation: 0 (‘I don’t have thoughts of killing myself’), 1 (‘I have thoughts of killing myself, but would never carry them out’), 2 (‘I would like to kill myself’), and 3 (‘I would try to kill myself if I had the chance’). Suicidal ideation was classified as any thoughts of self harm (1–3). We calculated a modified BDI affective subscale excluding the suicidal ideation item and somatic depressive symptoms that are confounded with HIV-related symptoms (Cronbach's α = 0.86).
Using binary logistic regression study sites, demographics, illness-related burdens, alcohol and substance use, and psychosocial factors were entered as predictors of suicidal ideation. Model fit was evaluated using the Hosmer and Lemeshow goodness of fit test.
Site differences were effect coded with San Francisco as the reference group. Ethnicity was also effect coded with African-American as the reference group, compared with Caucasian, Hispanic/Latino, and other ethnic minority participants. Gender was effect coded with men as the reference group, compared with women and transgendered participants. Education was effect coded with less than high school as the reference group, compared with high school graduates and those with at least some college. Lesbian, gay, bisexual, and questioning (LGBQ) participants (1) were compared with heterosexuals (0). Participants in a primary relationship (1) were compared with single participants (0). We compared participants who were homeless in the past year (1) with those who were not (0). We also examined detectable (1) versus undetectable (0) HIV viral load and CD4 cell counts less than 200 cells/μl (1) compared with 200 cells/μl or greater (0). The regular use of alcohol, marijuana, heroin, stimulants (cocaine, crack, or amphetamines), club drugs (ecstasy, ketamine, or GHB), and barbiturates was coded as 1 (two to three times per week or more) versus 0 (once a week or less). Individuals reporting any injection drug use in the past year (1) were compared with those who denied it (0). Continuous predictors were transformed into z-scores (M = 0, SD = ±1).
Most participants were male (75%), but 24% were female and 1% were transgendered. The majority of participants were LGBQ (61%) and African American (46%). However, 28% were Caucasian and 20% Hispanic/Latino. Mean age was 41.6 (SD = 7.6) years, and the sample was largely well-educated with 50% having completed at least some college. Approximately 14% reported being homeless in the past year, and 55% were single. The mean time since HIV diagnosis was 8.6 (SD = 4.6) years and 76% were prescribed ART.
Rates and correlates of suicidal ideation
Approximately 19% of participants (561/2909) reported thoughts of suicide in the past week. Of those participants who reported suicidal ideation, 7% (41/561) indicated that they would like to kill themselves or would kill themselves if they had the chance. We observed good model fit as evidenced by the non-significant Hosmer and Lemeshow chi-square statistic (χ2 (8) = 12.60, P > 0.10). In the final model (Table 1), we observed significant correlates of suicidal ideation across all five categories examined. Participants in Los Angeles and those who identified as Hispanic/Latino were 21% less likely to report suicidal ideation. LGBQ participants were 47% more likely to report suicidal ideation. Irrespective of sexual orientation, individuals in a primary relationship were 23% less likely to report suicidal ideation. Participants who reported more severe symptoms and side effects were 15% more likely to report suicidal ideation. Those reporting the regular marijuana use were 34% more likely to report suicidal ideation. Participants with elevated affective symptoms of depression were approximately 1.5 times more likely to report suicidal ideation. Finally, individuals with enhanced coping self-efficacy were 18% less likely to report suicidal ideation.
Consistent with previous investigations of HIV-positive persons [1,2], suicidal ideation in the current study was common, but the vast majority of individuals denied any suicide intent. Interestingly, Hispanic/Latino participants were less likely to report suicidal ideation. Cultural norms such as moral objections to suicide may explain lower rates of suicidal ideation, but Hispanic/Latino individuals have similar rates of suicide intent and suicide attempts when compared with other ethnic groups . Although further research is warranted, a culturally competent assessment of Hispanic/Latino individuals should examine whether generational status and acculturation stress influence mental health outcomes . The results also indicated that LGBQ individuals were at elevated risk of suicidal ideation, which may be partly explained by the increased stigma, discrimination, and physical violence experienced by this population [10,27,28]. Irrespective of sexual orientation, individuals in a primary romantic relationship were less likely to report suicidal ideation, and this may be because of the enhanced social support received from a primary partner [1–3]. Finally, although there were no differences in suicidal ideation by gender, future investigations are necessary to examine gender differences in suicide intent and attempts.
Over and above demographic characteristics, participants who rated HIV symptoms and ART side effects as more severe were more likely to report suicidal ideation. This highlights the importance of poor quality of life as a crucial determinant of suicidal ideation in HIV-positive individuals . Potentially lending further support to this conclusion, the regular use of marijuana was associated with suicidal ideation. HIV-positive individuals may use marijuana recreationally, to manage negative moods, improve appetite, and decrease nausea [30,31]. Although previous investigations have determined that cannabis dependence is associated with an increased risk of a major depressive disorder , the results of the present study indicate that regular marijuana use was an independent correlate of suicidal ideation after accounting for affective symptoms of depression. Regular marijuana use may assist HIV-positive individuals with managing specific, debilitating HIV symptoms and ART side effects that are related to suicidal ideation. Finally, individuals with enhanced confidence in their ability to cope adaptively with stress were less likely to report suicidal ideation, independent of the effect of affective symptoms of depression. Stress management interventions have been designed to assist HIV-positive individuals with enhancing coping skills to improve psychosocial adjustment [22,33], and these treatments may serve as an important form of support for individuals experiencing suicidal ideation. It is important to note, however, that we examined the rates and correlates of suicidal ideation in a community-based sample of HIV-positive individuals. Further studies should investigate rates and correlates of suicidal ideation in samples of HIV-positive individuals who present in clinical settings. Although longitudinal investigations are necessary to replicate these findings, results from the present study will assist with identifying HIV-positive individuals who may be at an increased risk of suicidal ideation so that they may can be assessed regularly and referred for psychological treatment when appropriate.
The authors would like to thank those at NIMH: Ellen Stover, PhD, and Willo Pequegnat, PhD, for their technical assistance in developing the study and Christopher M. Gordon, PhD, and Dianne Rausch, PhD, for their support of this research. Gratitude is also given to Susan Tross, PhD, and Gary Dowsett, PhD, for methodological guidance, to the assessors in each city who conducted the interviews, to the clinic and community-based organization collaborators, to all other support staff involved in the project, and to the men and women who participated in the interviews.
This study was conducted by the NIMH Healthy Living Trial Group.
Research steering committee (site principal investigators and NIMH staff collaborator): Margaret A. Chesney, Anke A. Ehrhardt, Jeffrey A. Kelly, Willo Pequegnat, Mary Jane Rotheram-Borus.
Collaborating scientists, co-principal investigators and investigators: Eric G. Benotsch, Michael J. Brondino, Sheryl L. Catz, Edwin D. Charlebois, Don C. DesJarlais, Naihua Duan, Theresa M. Exner, Rise B. Goldstein, Cheryl Gore-Felton, A. Elizabeth Hirky, Mallory O. Johnson, Robert M. Kertzner, Sheri B. Kirshenbaum, Lauren E. Kittel, Robert Klitzman, Martha Lee, Bruce Levin, Marguerita Lightfoot, Stephen F. Morin, Steven D. Pinkerton, Robert H. Remien, Fen Rhodes, Susan Tross, Lance S. Weinhardt, Robert Weiss, Hannah Wolfe, Rachel Wolfe, Lennie Wong.
Data management and analytical support: Philip Batterham, Tyson Rogers.
Site project coordinators: Kristin Hackl, Daniel Hong, Karen Huchting, Joanne D. Mickalian, Margaret Peterson.
NIMH: Christopher M. Gordon, Dianne Rausch, Ellen Stover.
Sponsorship: This research was funded by National Institute of Mental Health grants U10-MH57636, U10-MH57631, U10-MH57616, and U10-MH57615; and NIMH center grants P30-MH058107 (Mary Jane Rotheram-Borus, PhD, PI), P30-MH57226 (Jeffrey A. Kelly, PhD, PI), P30-MH43520 (Anke A. Ehrhardt, PhD, PI), and P30-MH062246 (Thomas J. Coates, PhD, PI). Additional support was provided by a Ruth L. Kirschstein National Research Service Award (T32-MH019391).
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