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Symptoms of depression, anxiety, and thoughts of suicide/self-injury in adolescents and young adults living with HIV in Botswana

Integrating mental health screening into youth HIV care

Published onJan 20, 2023
Symptoms of depression, anxiety, and thoughts of suicide/self-injury in adolescents and young adults living with HIV in Botswana
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Corresponding author: Merrian J Brooks; Email address: brooksm2@chop.edu

 

Acknowledgement

We wish to acknowledge the MoH/BBCCCOE for maintaining the cohort of YLWH and in-kind support of the project.

Abstract

Globally, mental health problems have been reported to be more common in youth living with HIV (YLWH) than in the general population, but routine mental health screening is rarely done in high-volume HIV clinics. In 2019, YLWH in a large HIV clinic in Botswana were screened using the Generalized Anxiety Scale-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) in a pilot standard-of-care screening program. Two-way ANOVA was used to describe the effects of age group (12-<16, 16- <20, and 20-25 years) and gender on GAD-7 and PHQ-9 scores. Chi square statistics were used to compare characteristics of YLWH with and without potential suicidality/self-harm symptoms based on question 9 on the PHQ-9. Among 1 469 YLWH, 33.1%, 44.3% and 15.0% had anxiety, depression, and potential suicidality/self-harm symptoms. YLWH aged 20-25 and 16-<20 had higher GAD-7 scores compared to 12-<16-year-olds (p=0.014 and p=<0.001, respectively). Female YLWH aged 20-25 had higher PHQ-9 scores compared to 12-<16-year-olds (p=0.002).  There were no other gender age dynamics that were statistically significant. Female YLWH endorsed more thoughts of suicidality/self-harm than males (17% vs. 13%, p=0.03, respectively).  Given the proportion of YLWH with mental health symptoms, Botswana should enhance investments in mental health services for YLWH, especially for female young adults who bear a disproportionate burden.

 

Key words: Adolescents and youth persons with HIV, symptoms of mental health disorders, Resource-limited settings

 

Introduction

 

Mental health in all adolescents

Globally, 13% of adolescents aged 10-19 years’ experience some form of mental disorder with depression, anxiety and behavioural problems being the most common causes of morbidity and mortality in this population (World Health Organization, 2021). The World Health Organization indicates that the prevalence of anxiety among persons aged 10-14 years and 15-19 years is 3.6% and 4.6%; whereas the prevalence of depression is 1% and 2.8%, respectively (World Health Organization, 2021). Recently it has become clear that sub-Saharan African youth are deeply affected by mental illness, with 20 to 30% of youth showing symptoms of common mental disorders such as anxiety, depression, and suicidal ideation (Jörns-Presentati et al., 2021).

Serious sequelae of common mental disorders such as death by suicide are also common. Suicide is the fourth leading cause of death among male adolescents aged 15 to 19 years and third leading cause among females of the same age (UNICEF, n.d.,; World Health Organization, n.d.,) . In 2019, the age-standardized suicide rate in Africa was 11.25 per 100 000 population (World Health Organization, 2019). The 2016 Botswana Youth Risk Behavioural Surveillance Survey (YRBSS) (where 9.6% self-reported a positive HIV status) showed that 22.4% of school-going 13-19-year-olds in Botswana had thought about committing suicide in the 12 months preceding the interview with 22.3% having planned to commit suicide and 19.4% having attempted suicide (Republic of Botswana, 2016b).

 

Mental health disorders among YLWH

People living with HIV (PLWH) are known to have higher rates of neuropsychiatric illnesses, including poor cognitive function, substance use, and mood disorders, than the general population (Gupta et al., 2010; Lawler et al., 2010). These may be related to the combination of HIV’s effects on the brain, side effects of antiretroviral medicines, and social determinants such as stigma, isolation, and poverty (Mellins & Malee, 2013). In Botswana, HIV prevalence is 3.4% among 15–24-year-old persons and incidence in this age group is the highest of all age groups in Botswana (Gouws, Stanecki, Lyerla, & Ghys, 2008; Republic of Botswana, 2021).  Among these adolescents in Botswana, poor HIV medication adherence has been shown to be associated with psychosocial dysfunction, contributing to repeating cycles of physical and mental illness in this vulnerable group (Lowenthal et al., 2012; Yang et al., 2018).

The global prevalence of anxiety and depressive disorders in YLWH is as high as 48.2% and 44.0%, respectively (Too et al., 2021). Among adolescents living with HIV in Africa, the pooled prevalence of any psychiatric disorder is 27% (Dessauvagie et al., 2020; A. A. Olashore, Paruk, Akanni, Tomita, & Chiliza, 2021). Suicide is ranked among the top 10 causes of death among adolescents aged 10 to 19 years in Africa and globally and suicidal ideation was found to be up to one in two in a small sample of university students with a mean age of 20 years in Botswana (Korb & Plattner, 2014). In Botswana, 9-12% of PLHIV had suicidal ideation (Lawler et al., 2011).

 

Screening and management of mental health disorders

There are routinized standardized screening procedures for tuberculosis (TB), respiratory tract infections, and cervical cancer for those being monitored for HIV (Republic of Botswana, 2016a). However, generally, routine screening for mental health disorders does not occur in HIV clinical care in resource-limited settings (Yemeke et al., 2020). In the absence of screening and timely diagnosis, untreated anxiety and depression contribute to poor health outcomes overall.

Untreated anxiety and depression can impair executive functioning, cognition, and reality testing, promoting sexual indiscretion with the potential of increased HIV transmission (Bere et al., 2017). With HIV, there is also an association between mental illness and poor HIV medication adherence (Yang et al., 2018). Going into adulthood, mood disorders are associated with other long-term inflammatory diseases (Skovlund, Mørch, Kessing, & Lidegaard, 2016) such as heart (Lopez-Candales, Hernández Burgos, Hernandez-Suarez, & Harris, 2017) and kidney disease (Silverstein, 2009), which can decrease overall quality and length of life. Given the positive advances made in HIV treatment, this would be a particularly devastating outcome (Benton, Ng, Leung, Canetti, & Karnik, 2019).

 

Objective

Infectious diseases clinics serving YLWH need to understand the overall burden of mental illness in their populations to expand the meaning of ‘comprehensive HIV care’ to include co-morbid mental illness, like the incorporation of TB into HIV care earlier in the epidemic. In this study, we assessed the prevalence of symptoms of anxiety and depression and suicidality/self-harm in a large cohort of youth aged 12 to 25 years living with HIV in a referral clinic in Gaborone, Botswana. We used clinically relevant commonly used scales to better understand the mental health service needs of YLWH in low and middle income (LMIC) settings.

Methods

Study design and setting

The study is a data analysis of a mental health screening program that was a pilot quality improvement project implemented at Botswana Baylor Children’s Clinical Centre of Excellence clinic in Gaborone, Botswana, between 1st January 2019 and 31st December 2019. Botswana Baylor Children’s Clinical Centre of Excellence, which was launched in June 2003, had an active patient enrolment of approximately 2 426 clients at the time of inception of this study. This secondary data analysis was approved by the Botswana national IRB, The Botswana Baylor Children’s Clinical Centre of Excellence IRB, and the University of Pennsylvania IRB.

 

Study population

Youth aged 12 to 25 years who had not undergone screening for symptoms of anxiety and depression within the 12 months preceding the study date, and who were visiting the clinic for routine monitoring and/or medication refills during the study period we included.  Youth who were screened within the 12 months preceding the intervention period were ineligible for screening. Clients were able to ‘opt out’ of this routine screening process for symptoms of mental health disorders.

 

Screening tools

Data were extracted from the clinics mental health screening program database. We extracted scores from the Generalized Anxiety Scale-7 (GAD 7) (Mossman et al., 2017) and Patient Health Questionnaire-9 (PHQ-9) (Keum, Miller, & Inkelas, 2018; Kroenke, Spitzer, & Williams, 2001; Löwe et al., 2008) for this study. Both the GAD-7 and PHQ-9 are used to screen for symptoms of anxiety and depression that would warrant further inquiry, respectively.

The GAD-7 has questions related to symptoms that would be associated with a diagnosis of generalized anxiety disease; feeling nervous or anxious or on edge, being unable to stop/control worrying, worrying too much about different things, trouble relaxing, being so restless that it is hard to sit still, becoming easily annoyed or irritable, and feeing afraid as if something awful would happen. It was possible to attain a minimum score of zero and a maximum score of 21 depending on frequency of symptoms over the past two weeks. Scores were interpreted as no/minimal anxiety (<5), mild anxiety (5-9), moderate anxiety (10-14) and severe anxiety symptoms (15-21) (Mossman et al., 2017; Spitzer, Kroenke, Williams, & Löwe, 2006). 

 

The PHQ-9 has questions related to the symptoms of major depressive disorder; including interest or pleasure in doing things, feeling down or depressed or hopeless, problems sleeping, feeling tired or unenergetic, feeding problems, feeling bad about oneself, moving too slowly or being fidgety, and feeling that you would be better off dead. There is a minimum score of zero and a maximum score of 27 based on frequency of symptoms over the previous two weeks. Scores were interpreted as no/minimal depression (<5), mild depression (5-14), moderate depression (5-14), moderately severe depression (15-19), and severe depression symptoms (20-27) (Kroenke et al., 2001). The last question on the PHQ-9 was also used to assess for potential suicidality/self-harm. Any score of > 0 (i.e., 1, 2 or 3) of the last question of the PHQ-9 was considered indicative of potential suicidal ideation or self-harm since these scores indicated having thoughts that you would be better off dead or have thoughts of hurting yourself in some way 1) several days, 2) More than half the days, or 3) nearly every day. The PHQ-9 questions dichotomized form called the Mood Module has been validated in youth in southern Africa (Cholera et al., 2014) and used in PLWH including in Botswana (Lawler et al., 2011; Tommasello, Gillis, Lawler, & Bujak, 2006).   

 

Data management and analysis

After the mental health screening data were extracted. The data were then exported into Statistical Package for Social Sciences (SPSS) Ver 27 software (IBM, Chicago, USA) for analysis. Both the PHQ-9 and GAD-7 were assessed for reliability using Cronbach alpha. We analysed data for all youth who completed all questions on the surveys. Frequencies and measures of central tendency were used to assess for data completeness and distribution. Normally distributed data were summarized using means and standard deviations. Skewed data were summarized using medians and IQR. Proportions were used to summarize the number of clients reporting no/minimal, mild, moderate, and severe anxiety symptoms, among all clients and among clients with anxiety (i.e., reporting any symptom of anxiety). Similarly, proportions were used to summarize the number of clients reporting no/minimal, mild, moderate, moderately severe, and severe depression symptoms, among all clients and among clients with depression (i.e., reporting any symptom of depression).

A two-way ANOVA was conducted to compare the main effects of gender and different age groups as well as their interaction on PHQ-9 and GAD-7 scores. Post hoc pairwise comparisons were conducted for those variables with the statistically significant omnibus test. The significance level (p-value) was set at <0.05, and a Bonferroni correction to the type I error rate was applied to pairwise comparisons.

Proportions were also used to summarize the number of clients reporting symptoms of suicidal ideation. Chi square statistics and Fisher exact test were used to compare characteristics of participants expressing potential suicidal ideation or self-harm to those of participants who did not express potential suicidal ideation or self-harm.

Results

Participant selection

A total of 1 482 adolescents and youth were screened from 1st January to 31st December 2019. We excluded 13 who did not complete both screening evaluations (12 underwent screening for anxiety only and 1 depression only) from our primary analysis, leaving 1 469 who were included in the final analysis.

 

Participant demographic characteristics

Of the 1 469 clients who underwent screening for both anxiety and depression, the slight majority (51.1%) were male and aged 16-<20 years (51.8%) (Table 1).

Supplementary table 1: The mean scores and standard deviations for GAD-7 and PHQ-9 for all YPLH, Bostwana, 2019

 

GAD-7 and PHQ-9 validation

The Cronbach alphas were 0.806 and 0.743 for the GAD-7 and the PHQ-9, respectively.

 

GAD-7 screening severity level, age, and gender

A total of 31.6% of clients had symptoms of anxiety. Among all analysed clients, GAD-7 screening outcomes were mild anxiety (22.5%), moderate anxiety (8.2%), and severe anxiety symptoms (2.9%) (Table 1). 

The proportion of clients who screened positive for anxiety symptoms increased with age; however, this did not attain statistical significance (p=0.100) (Table 1). Simple main effects analysis showed that age group had a statistically significant effect on the GAD-7 score (p = 0.002). YLWH aged 20-25 and those aged 16-<20 years had significantly higher rates of anxiety symptoms when compared to 12-<16-year-olds (p=0.036 , 95% CI -1.370, -0.030, and p=<0.001, 95% CI -1.860, -0.380, respectively) (Table 2).

Table 2: Pairwise comparisons of PHQ9 and GAD7 scores according to age groups for all YPLH, Botswana, 2019 (both male and female)

A similar proportion of female clients reported anxiety symptoms when compared to male clients (34.6% vs 32.5%, p=0.395 for female and male clients, respectively). The breakdown of mild/moderate/severe symptoms is outlined in Table 1.

The higher mean GAD-7 scores seen in female participants when compared to male participants (4.1±4.3 vs. 3.8±3.9 respectively), were not significantly different (p=0.065) (Supplementary Table 1).   

A two-way ANOVA to analyse the effect of age group and gender on the total GAD-7 score illustrated the absence of a statistically significant interaction between the age group and gender (p =0.832) (data not shown).

Frequency of specific anxiety symptoms 

The most reported anxiety symptoms by all clients screened (n=1469) were worrying too much about different things, becoming easily and not being able to stop or control crying reported by 52%, 52% and 36% of all clients, respectively.  Of note, only 463 of all screened clients met the criteria for having mild, moderate or severe anxiety symptoms (GAD-7≥5). (Supplementary Figure 1).

The most reported anxiety symptoms by only clients screening positive for anxiety symptoms (n=493) were worrying too much about different things, becoming easily annoyed or irritated and not being able to stop or control crying reported by 88%, 85% and 75% of clients (Supplementary Figure 1).

The most reported anxiety symptoms by only clients screening positive for severe anxiety symptoms (n=42) were worrying too much about different things, not being able to stop or control crying and feeling afraid as though something awful may happen reported by and 100%, 100% , 98% and 93% of clients. (Supplementary Figure 1).

Supplementary figure 1: The most reported anxiety symptoms by all clients screened (n=1469 ) were worrying too much about different things, becoming easily and not being able to stop or control crying reported by 52%, 52% and 36% of all clients, respectively.  Of note, only 463 of all screened clients met the criteria for having mild, moderate or severe anxiety symptoms (GAD-7≥5).

The most reported anxiety symptoms by only clients screening positive for anxiety symptoms (n=493) were worrying too much about different things, becoming easily annoyed or irritated and not being able to stop or control crying reported by 88%, 85% and 75% of clients.

The most reported anxiety symptoms by only clients screening positive for severe anxiety symptoms (n=42) were worrying too much about different things, not being able to stop or control crying and feeling afraid as though something awful may happen reported by and  100%, 100% , 98% and 93% of clients.

 

PHQ-9 screening severity level, age, and gender

A total of 44.3% of clients had symptoms of depression. Among all analysed clients, PHQ-9 screening outcomes were mild depression (28.9%), moderate depression (10.9%), moderately severe depression (3.6%), and severe depression symptoms (0.9%) (Table 1). 

Table 1: Screening outcomes for anxiety symptoms using GAD-7 and depression symptoms using PHQ-9 for YPLV in Gaborone, Botswana, 2019

The proportion of clients that screened positive for depression increased significantly with an increase in the age-group (p=0.048) (Table 2). The mean PHQ-9 scores also, increased with age-group (Supplementary Table 1). Simple main effects analysis showed that age group did have a statistically significant effect on the PHQ-9 score (p = 0.009) (data not shown). YLWH aged 20-25 had significantly higher rates of symptoms of depression when compared to 12- <16-year-olds (p=0.005 , 95% CI -1.870, -0.260) (Table 2).

The proportion of clients reporting depression symptoms did not differ by gender (46.9% vs 41.9%, p=0.054 for female and male clients respectively). However, there was a significantly higher proportion of female clients reported moderate, moderately severe, and severe depression symptoms when compared to male clients (12.4% vs 9.6%, 4.7% vs 2.5% and 1.1% vs 0.7% for female and male clients respectively, p=0.041) (Table 1). The mean PHQ-9 scores were significantly higher in female participants when compared to male participants (5.3±4.8 vs. 4.7±5.2 respectively, p<=0.001) (Supplementary Table 1).

A two-way ANOVA to analyse the effect of age group and gender on the total PHQ-9 score showed the association between age-group and PHQ-9 scores did not differ by gender (p =0.686) (data not shown).

Frequency of specific depression symptoms  

Among all clients screened (n=1469), the most reported symptom was feeling tired or having little energy, poor appetite or overeating, and trouble falling or staying asleep or sleeping too much reported by 52%, 42% and 41%, respectively. Notably, some of these clients who may have screened positive for single or multiple symptoms of depression, may not have met the threshold for being categorized as having mild symptoms of depression (PHQ-9≥5) (Supplementary Figure 2).

Among those who screened positive for depression (n=651), the most reported symptoms were feeling tired or having little energy, trouble falling or staying asleep or sleeping too much, and feeling down, depressed, and hopeless reported by 76%, 66% and 66% of clients respectively (supplementary figure 2).

The most reported depression symptoms by only clients screening positive for moderately severe and severe depression symptoms (n=66) were feeling tired or having little energy, trouble falling or staying asleep or sleeping too much, feeling down depressed or hopeless and trouble concentrating on things reported by 94%, 94%, 94% and 94% of clients with moderately severe and severe depression symptoms, respectively (supplementary figure 2).

Supplementary figure 2: Among all clients screened (n=1469), the most commonly-reported symptom was feeling tired or having little energy, poor appetite or overeating, and trouble falling or staying asleep or sleeping too much reported by 52%, 42% and 41%, respectively. Notably, some of these clients who may have screened positive for single or multiple symptoms of depression, may not have met the threshold for being categorized as having mild symptoms of depression (PHQ-9≥5).

Among those who screened positive for depression (n=651), the most commonly reported symptoms were feeling tired or having little energy, trouble falling or staying asleep or sleeping too much, and feeling down, depressed and hopeless reported by 76%, 66% and 66% of clients respectively.

The most reported depression symptoms by only clients screening positive for moderately severe and severe depression symptoms (n=66) were feeling tired or having little energy, trouble falling or staying asleep or sleeping too much, feeling down depressed or hopeless and trouble concentrating on things reported by 94%, 94%, 94% and 94% of clients with moderately severe and severe depression symptoms, respectively with half (or close to half) of them experiencing these symptoms nearly every day.

 

 

Clients reporting both anxiety and depression symptoms

A total of 409 (27.8%), clients reported both anxiety and depression symptoms, 242 (16.5%) reported depression symptoms alone and 84 (5.7%) reported anxiety symptoms alone. The remainder (n=734; 50.0%) did not meet the threshold for mild symptoms of anxiety or depression.

Among those who reported both depression and anxiety symptoms (n=409), 26 (6.4%) had both severe anxiety symptoms and moderately severe or severe depression symptoms), 16 (3.9%) had severe anxiety symptoms with mild and moderate symptoms of depression, 38 (9.3%) had moderately severe and severe depression symptoms with mild anxiety symptoms. The remainder (n=329; 80.4%) had milder symptoms. A detailed analysis of these symptoms is shown in Supplementary Table 2.  

Supplementary table 2: YPLH screening positive for both anxiety and depression symptoms, Botswana, 2019

 

Screening outcomes for potential suicidal ideation or self-harm

The self-injury/suicide question (SI/SQ) was endorsed by 224 (15.0%) clients; 8.2% had such thoughts for several days in the two weeks preceding the interview, 3.4% for more than half the days preceding the interview, and 3.6% nearly every day preceding the interview.  

There was no statistical difference among the different age groups on the rate of those endorsing suicidality; however, more female than male clients reported suicidality (17.0% vs. 13.0%; p=0.026). Of those endorsing suicidality, 60 (26.7%) and 31 (13.8%) were categorized as having ‘no symptoms of anxiety’ and ‘no symptoms of depression,’ respectively based on their total GAD-7 and PHQ-9 scores. A higher proportion of participants thought they would be better off dead or wished to hurt themselves with increasing severity levels of anxiety (p<0.001) and depression (p<0.001) (Table 3).

Table 3: Screening outcomes for potential suicidal ideation and self-harm (Q9 on the PHQ9) by sex and age-group

 

Discussion

In this large cohort of YLWH, almost half had symptoms of at least mild depression or anxiety or both. Not surprisingly, older YLWH were at highest risk (World Health Organization, 2021). A significant proportion of those with symptoms had both anxiety and depression symptoms. Importantly, a high proportion who endorsed suicidal ideation or self-harm, did not reaching thresholds to be defined as having mild anxiety or depression symptoms.

The prevalence of anxiety and depression in the present study is slightly higher than the pooled prevalence reported in the recent systematic review of African studies, which found 26% and 24%, respectively (A. A. Olashore et al., 2021). This may have been due to fact that our population was composed exclusively of YLWH or related to differences in the age groups included in our study vs in the systematic review. The systematic review included children as young as 3 years and no youth aged > 19 years (Slogrove & Sohn, 2018). The systematic review included both children diagnosed with and presenting with symptoms of mental illness using a variety of different measures. Rates of depression disorder symptoms in the present survey were slightly higher than Woolett and colleagues (2017), who reported a depression rate of 27% in a similar population using a diagnostic tool (MINIKID) to screen, as opposed to the a self-administered PHQ-9 screening tool (Woollett, Cluver, Bandeira, & Brahmbhatt, 2017). Overall, our results are consistent with the smaller published studies (sample sizes 82-222) conducted in other YLWH in African countries which have shown 15 to 50% prevalence of mood disorders based on diagnostic rather than screening criteria (Ashaba et al., 2018; Bankole et al., 2017; Kemigisha et al., 2019; Musisi & Kinyanda, 2009).

Older adolescent and young adult women have higher rates of depression and anxiety than their young male counterparts (A. A. Olashore et al., 2021) and YLWH, and those without these symptoms show an increase in mood disorders as they get older (UNICEF, n.d.,; World Health Organization, n.d.,). Notably, adolescent boys and young men are often missed by common screeners (Porsche & Giorgianni, 2020) and indeed a reverse gender trend has been see in in adults with HIV in Botswana (Gupta et al., 2010). If this is the case, the small trends and insignificant gender differences may represent this discrepancy. Our study is in line with the known relationship between the two disorders where globally about 2 in 5 people with anxiety will also report depressive symptoms and vice versa (Kalin, 2020). 

 

Exploring Suicide or Self Harm

Using the last question on the PHQ-9, 15% of YLWH reported potential suicidal ideation and self-harm. The rate of youth answering yes to the SI/SQ in our population are similar to those found in a number of other studies with smaller samples of adolescents in Africa where rates were between 10% and 17% mostly using the MINI International Psychiatric Interview for Children and Adolescents Suicide questions MINIKID-SD (Ashaba et al., 2018; Namuli, Nalugya, Bangirana, & Nakimuli-Mpungu, 2021; Rukundo et al., 2020). Slightly higher rates of suicidality were seen on the MINIKID-SD by Woollet et al, with 24% of 13-17 year-olds living with HIV in South Africa having suicidality (Woollett et al., 2017). However, in the only other study with a similar sample size to ours (n=1 058), Sherr et al (2018) found that 4.1% of youth had suicidality on the MINIKID-SD (Sherr, Cluver, Toska, & He, 2018). The MINIKID-SD is an interviewer administered questionnaire and thus provide a more comprehensive assessment of suicidality and thus more likely to yield more accurate results when compared to a single screening question on the PHQ-9 (Rukundo et al., 2020; Sheehan et al., 1998). Thus, our screening results show rates that are similar to smaller studies in African YLWH but add some heterogeneity to the work done by Sherr. There are clear limitations to assessing suicide using the SI/SQ questions however, the similarity of our findings in a larger dataset, to other youth populations in Africa with smaller samples is truly concerning. This initial screening prompts further exploration into serious sequelae of mental illness in YLWH.

Notably, several clients who screened negative for possible depression or anxiety also replies ‘yes’ to the SI/SQ, suggesting that some patients who are classified as having no symptoms of anxiety or depression based on total GAD-7 or PHQ-9 scores might still have self-injurious thoughts or acts. Suicide and self-injury are complex and can be associated with mental illnesses other than depression and anxiety, life stressors/impulsivity, or chronic disease (A. A. Olashore et al., 2021). Suicidality specifically in YLWH may also be triggered by low socioeconomic status, orphanhood (disproportionately affecting YLWH), and the unique challenges of HIV stigma, and HIV wasting syndrome (Namuli et al., 2021; Rukundo et al., 2020).

 

Strengths

The strengths of this study are in its large sample size, its demographic delineations, and its comprehensive assessment using two validated clinically relevant mental health symptoms screening tools. It also includes depression, anxiety and suicide/self-injury providing a granular analysis of what specific mental disorders might be affecting this population. It is also advanced by its setting within a large referral HIV clinic in a resource limited setting that bears the brunt of the HIV burden among adolescents and young persons living with HIV.

 

Limitations

There were some limitations mostly related to the limits of screening measures. Firstly, the screening measures used are designed to identify symptoms of depression and anxiety and would require confirmation using the gold standard of interviews by mental health professional.  The findings however are relevant, given that symptoms of anxiety or depression, or anxiety and depression have been demonstrated to interfere with adherence to treatment, and are associated with morbidity and mortality (Skovlund et al., 2016; Yang et al., 2018). Though the screening questions cannot diagnose depression and anxiety, they are correlated with commonly used diagnostic tools (Lawler et al., 2011; Löwe et al., 2008) indicating that the rates from our study warrant further exploration. Secondly, though cut-off points for clinically relevant mental illness are established using populations of youth throughout the world, the cut points may also need to be adjusted (i.e., does a score of 5 on the PHQ-9 meaningfully correlate with impairment in this population?). Future validity testing will allow exploration of cultural and age-specific milieu for both the tools and the cut points in this population of mostly perinatally infected YLWH. Most youths in our sample had symptoms that when confirmed could be classified as mild to moderate depression or anxiety. When considering the impact of mild to moderate mental illness in youth, it is important to understand that symptoms of mental illness have a variety of trajectories (Chaiton et al., 2013; Fernández et al., 2022; Shore, Toumbourou, Lewis, & Kremer, 2018; Xu, Mishra, & Jones, 2019). Those with sustained high levels or low current but increasing levels are at risk for serious mental health morbidity and mortality from suicidal ideation, intentions, and actions. So even if the categories were clinically confirmed, the long-term implications would be uncertain without understanding the trajectory of the disease. Our findings are concerning in that older youth had the highest rates of both depression and anxiety indicating potentially sustained symptoms. Further studies should understand these trajectories that are not well explored in LMIC and especially not among YLWH. Lastly, the screening program was provided to YLWH in an urban setting and thus its results may not be generalizable YLWH in rural settings.

Further limitations to this study include limited demographics and follow-up data for outcomes. Subsequent work will explore the major precipitants and social factors that might contribute to the depression, anxiety and suicidal or self-injury symptoms and follow these precipitants and the symptoms over time. There are also limitations to anonymous screening techniques such as those used in this study particularly in younger adolescents or those with limited unidentified literacy concerns. Further work will explore these mental health outcomes prospectively and with diagnostic procedures.

 

Conclusions and recommendations

In Botswana, where resources to treat mental disorders are constricted, only adolescents with severe disorders such as psychosis and suicidal behaviours are referred for mental health treatment or hospitalizations (A. Olashore, Frank-Hatitchki, & Ogunwobi, 2017). This practice leaves out key opportunities to provide services for those with milder symptoms and to prevent more detrimental outcomes. As mental health interventions expand to include more community-based interventions to disrupt worsening psychiatric illness, it is the perfect time to screen and identify youths with less severe psychiatric cases and connect them to services (Bere et al., 2017; Das et al., 2016). Another recommendation might be to enact universal psychosocial support models that would target all clinic youth with evidence-based interventions specifically for mood disorders including depression and anxiety. Example interventions might include automatic assignments to group therapy, lay counsellor-based therapy, single session interventions, or social supports such as financial disbursements (Galagali & Brooks, 2020). There could be an additional layer of services that meet the needs of young women specifically to try and close the gap between male and female YLWH.

If, as in other studies, almost one in two YLWH have confirmed clinically significant depression, anxiety or both, mental health resources that include suicide-specific interventions, would be well placed to improve the overall health of these YLWH.


 

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