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vol.40 número1Comparación de niveles de ansiedad y depresión entre mujeres y hombres de una clínica de la Ciudad de México que viven con VIHFactores asociados con el riesgo de transmisión de VIH en personas con un trastorno mental grave. Una revisión narrativa índice de autoresíndice de assuntospesquisa de artigos
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Salud mental

versão impressa ISSN 0185-3325

Salud Ment vol.40 no.1 México Jan./Fev. 2017 

Original articles

Assessment of depression, anxiety, hopelessness and suicidal risk in HIV+ inpatients

Evaluación de depresión, ansiedad, desesperanza y riesgo suicida en pacientes con VIH hospitalizados

Cecilia Alderete-Aguilar1 

Rosa Cruz-Maycott1 

María Candela-Iglesias1 

Evelyn Rodríguez-Estrada1 

Gustavo Reyes-Terán1 

1Departamento de Investigación de Enfermedades Infecciosas,Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico



People living with HIV frequently experience anxiety, depression, hopelessness and suicide risk, particularly if they are hospitalized due to HIV complications.


The aim of this study was to evaluate the presence of anxiety, depression, hopelessness and suicide risk in HIV+ inpatients at admission and discharge.


A comparative study was conducted with the HIV+ inpatient population of the National Institute for Respiratory Diseases in Mexico City, from February to November 2013. The Hospital Anxiety and Depression Scale, the Beck Hopelessness Scale and the Plutchik Suicide Risk Scale were applied at hospital admission and discharge.


One hundred and fifteen patients completed all three assessments. Upon admission, 10.4% of the patients scored above the cut-off point for suicide risk; 1.7% presented high levels of hopelessness; 5.2% had clinical depression, and 7% had clinical anxiety. The comparison of scores at admission and discharge showed significant decreases in all symptom levels.

Discussion and conclusion.

Most of the patients presented low levels of all symptoms assessed at admission and these decreased at discharge. Further research is necessary with the hospitalized HIV population.

Keywords: Depression; anxiety; hopelessness; suicide risk; HIV; hospitalization



Las personas que viven con VIH experimentan con frecuencia ansiedad, depresión, desesperanza y riesgo suicida, particularmente si son hospitalizadas debido a complicaciones por el VIH.


El propósito del presente estudio fue evaluar y comparar la presencia de ansiedad, depresión, desesperanza y riesgo suicida en pacientes hospitalizados con VIH, a su ingreso y su egreso.


Se llevó a cabo un estudio comparativo con pacientes de VIH+ hospitalizados en el Instituto Nacional de Enfermedades Respiratorias en la Ciudad de México de febrero a noviembre de 2013. Se aplicaron la Escala de Ansiedad y Depresión Hospitalaria, la Escala de Desesperanza de Beck y la Escala de Riesgo Suicida de Plutchik.


Ciento quince pacientes completaron las tres escalas. A su ingreso, 10.4% de los pacientes obtuvieron puntajes por encima del punto de corte en la Escala de Riesgo Suicida; 1.7% presentaron niveles altos de desesperanza; 5.2% puntuaron con depresión clínica; y 7% puntuaron para ansiedad clínica. La comparación entre los resultados obtenidos al ingreso y el egreso hospitalario mostró una disminución significativa en todos los síntomas al egreso.

Discusión y conclusión.

La mayoría de los pacientes presentaron niveles bajos de los síntomas evaluados y éstos disminuyeron al egreso. Son necesarias investigaciones adicionales de salud mental en población hospitalizada con VIH.

Palabras clave: Depresión; ansiedad; desesperanza; riesgo suicida; VIH; hospitalización


Anxiety, depression, hopelessness and suicide risk are experienced more frequently by people living with HIV (PLWH) than by the general population ( Vargas-Mendoza, Cervan-tes-Ramírez & Aguilar-Morales, 2009 ), and are recognized risk factors associated with a lack of adherence to antiretroviral treatment (ART) and lower quality of life (Wolff, Alvarado & Wolff, 2010).

Most research on anxiety and depression in PLWH has been focused in the outpatient setting ( Govender & Schlebusch, 2012 ; Nogueira-Campos, De Fátima-Bonolo & Crosland-Guimaraes, 2006 ; Perdices, Dunbar, Grunseit, Hall & Cooper, 1992 ). In contrast, little is known about the prevalence of anxiety, depression, hopelessness and suicide risk among the inpatient HIV+ population. The evaluation of these aspects in HIV+ individuals requiring hospitalization may ensure prompt identification of mental health needs and an opportunity for early interventions.

The aim of this study was to identify the presence of anxiety, depression, hopelessness and suicide risk in HIV+ hospitalized patients in tertiary care hospital in Mexico City, as well as to compare the severity of symptoms at admission and discharge.



A comparative study with repeated measures within subjects design was conducted in the inpatient population of the Center for Research in Infectious Diseases (CIENI) of the National Institute of Respiratory Diseases (INER) in Mexico City.


From February to November 2013, a nonprobability convenience sample of newly diagnosed HIV+ individuals, as well as PLWH with previous diagnosis, admitted to hospitalization, were eligible to participate. Inclusion criteria were: confirmed HIV diagnosis, age >18 years, a nonscheduled hospitalization admittance and willingness to participate by providing verbal consent. Exclusion criteria were current substance dependence and patients not suitable to participate (e.g. altered state of consciousness, delirium, psychosis, cognitive impairment, dementia or mechanic ventilation assistance), assessed through a clinical interview.


A clinical interview and a set of clinimetric instruments were applied at hospital admission and discharge by trained psychologists. Anxiety and depression were assessed by the homologous sub-scales of the Hospital Anxiety and Depression Scale (HADS) ( Zigmond & Snaith, 1983 ). Cut-off points classify anxiety and depression symptoms into normal (≤ 7 points), probable cases (8-11 points) and clinical cases (≥ 12 points). Psychometric properties of these instruments in Mexican populations have been evaluated ( Nogueda-Orozco, Pérez-Terán, Barrientos-Casarrubias, Robles-García & Sierra-Madero, 2013 ).

The Spanish-adapted and validated version of the Beck Hopelessness Scale (BHS) was used to evaluate hopelessness ( Córdova-Osnaya & Rosales-Pérez ). BHS consists of 20 true or false propositions, cut-off points classify hopelessness into minimal ( < 3 points), mild (4-8 points), moderate (9-14 points) and severe (15-20 points) ( Aguilar García Iturrospe et al., 1995 ; Beck, Weissman, Lester & Trexler, 1974 ).

Suicide risk was assessed through the Plutchik Suicide Risk Scale (PSRS). PSRS is a 15-item self-reported measure that describes the degree to which an individual reveals characteristics similar to those of a suicide prototype ( Plutchik, Van Praag, Conte & Picard, 1989 ; Rubio et al., 1998 ). Cut-off is 6 points and discriminates those with suicide risk and a history of suicide attempts ( Plutchik, Van Praag, Conte & Picard, 1989 ; Rubio et al., 1998 ). Psychiatric diagnoses were established based on the MINI International Neuropsychiatric Interview ( Ferrando, Bobes & Gibert, 2000 ).

Demographic characteristics were collected through a clinical interview in order to identify a potential high risk profile due to sociodemographic or geographic residence aspects.

Relevant clinical data related to HIV status, such as CD4 cell counts (the measurement of the number of CD4 positive T- cells in a cubic millimeter of blood) and plasma viral load (viral load is the term used to describe the amount of HIV in a fluid) were obtained through medical record.

Statistical analysis

Descriptive statistics were used to describe basic demographic and clinical sample data. T-Student test for paired samples was used to compare clinimetric scores at admission and discharge. Statistical significance was set at p < 0.05. Statistical analysis was carried out using SPSS 20.0 (IBM).

Ethical considerations

Psychiatric consultation was provided to all patients scoring above the cut-off points for anxiety (HADS ≥ 11 points), depression (HADS ≥ 11), hopelessness (BHS ≥ 15 points) and suicide risk (PSRS ≥ 6 points). The study was approved by the Research and Ethics Committee of the INER.


Two hundred and fifty three HIV+ individuals were hospitalized from February to November 2013; 65% (n = 164) answered a clinimetric evaluation. Most of them (87%, n = 142) completed the assessment at hospital admission, and 71% (n = 117) at discharge. Missed discharge assessment were associated to hospital discharge before responding to clinimetric scales (n = 25). Two patients were not included in the analysis because they did not fulfill all clinimetric assessment at hospital admission. Data analysis was made with 115 participants who completed both assessments.

Ninety percent (n = 104) of the participants were male, with mean age 34.4 years (SD = 9.5, range 19-62); with an educational level equivalent to incomplete high school. Most were single (71.3%, n = 82) and were Mexico City residents (60.9%, n = 70). Half of the patients received their HIV diagnosis within the three months previous to hospitalization or during their stay at the hospital. Most were in their first hospitalization (86.1%, n = 99). Twelve percent (n = 14) corresponded to hospital readmissions, and all were readmitted within 12 months of their previous hospitalization.

At admission, fifty-two percent (n = 60) of the individuals were on ART and had a median viral load of 81,206 copies RNA-HIV per ml and CD4 count 75 cells/mm3. Ninety-eight percent (n = 113) were discharged by medical approval. Detailed sociodemographic and clinical characteristics are shown in table 1.

Table 1 Sociodemographic characteristics of patients 

Note: SD = Standard deviation; ma = Million

Status at admission

The psychometric assessment carried out upon entry to the hospital (table 2) showed that 10.4% (n = 12) of the HIV+ individuals had suicide risk and 5.2% (n = 6) had moderate to high levels of hopelessness. Probable and clinical depression and anxiety were present in 13.9% (n = 16) and 23.5% (n = 27), respectively.

Table 2 Suicide risk, hopelessness, depression and anxiety at hospital admission and discharge 

Note: SD = Standard deviation

Thirty seven patients (32.2%) received a psychiatric assessment: major depressive disorder was confirmed in 27% (n = 10), 5.4% (n = 2) had generalized anxiety disorder, and 67.6% (n = 25) had no formal psychiatric diagnosis. Nearly half of these (43%, n = 16) received psychopharmacologic treatment mainly due to delirium (with onset after initial assessment), or treatment of affective, anxiety and sleep disturbances.

Patients in our sample received a mean of five (SD = 3.2, range 1-17) individual sessions of psychological counseling focused on HIV education and emotional regulation strategies.

Status at discharge

Discharge evaluations showed that 9.6% (n = 11) of HIV+ individuals still showed suicide risk, 2.6% (n = 3) had moderate to high levels of hopelessness, 2.6% (n = 3) persisted with clinical depression and 6.1% (n = 7) had clinical anxiety symptoms.

Changes in symptoms between entry and discharge

Total scores in all measures had a significant decrease when compared with admission ones, as detailed in table 2.

Discussion and conclusion

Our results showed that most HIV+ inpatients in our sample presented normal levels of anxiety and depression, minimum levels of hopelessness and had no suicide risk at hospital admission; a significant decrease in all symptoms was observed at discharge in all these variables. To our knowledge, this is the first study in an HIV+ inpatient population comparing these variables at hospital admission and discharge.

Our results mimic those found in Brazil by Garcia-Capitão et al. (2011) , who found similar levels of anxiety and depression in HIV+ inpatients. These similarities may be due to comparable low CD4 T-cell count ( < 200 cells/mm3) in both samples. CD4 T-cell counts correlate with physical symptoms and counts below 200 cells/mm3 refer to an AIDS stage of the infection. Some studies have shown that depression and anxiety symptoms in PLWH can increase in parallel to the magnitude of physical deterioration, being higher in AIDS stages of HIV infection ( Perdices et al., 1992 ; Wolff et al., 2010 ).

In our cohort, however, prevalence of depression (5.2%) and anxiety (7%) at admission were lower than other general in-hospital populations where prevalence ranges from 41.3% to 46.5% ( Rothenhäusler, 2006 ) and, surprisingly, lower than those reported in outpatient PLWH populations (range from 10% to 87%) ( Nogueira-Campos et al., 2006 ). This may be due to low levels of anxiety and depression in the general HIV+ population.

Contradictory findings have been published concerning a potential relation between affective symptoms and length of hospital stay. Some studies reported a decrease in depression and anxiety after the third day of hospitalization ( Costas-González, Prado-Robles & Crespo-Iglesias, 2013 ; Kathol & Wenzel, 1992 ), while others reported the persistence of symptoms throughout hospitalization ( Grau et al., 2007 ). Different variables could influence the decrease in the severity of symptoms at time of discharge observed in our sample, such as improvement in physical condition, psychopharmacological treatment where needed and counseling sessions. However, no statistical differences in decrease in symptoms were found between those receiving and not receiving counseling and bedside psychotherapy (data not shown). Further studies will be required in order to tease out the influence of these variables in improvement of symptoms.

The hopelessness and suicide risk levels found in our study are also lower than those reported in HIV outpatient populations, where nearly 20% of patients reported suicidal ideation and hopelessness ( Govender & Schlebusch, 2012 ).

Limitations of the study include the exclusion of patients with substance dependence, the fact that we did not collect other psychopathological variables ‒such as past psychiatric history‒ and that not all individuals completed both assessments. It is possible that patients that did not complete both assessments presented higher levels of anxiety and affective symptoms, although no differences were found in basic sociodemographic characteristics when comparing these two groups (data not shown). Main reasons for non-completion of assessments were inability to be evaluated due to discharge over the weekend or death. Assisted application of the instruments was made whenever possible.

Despite these limitations, the evaluation proposed in this study helped to identify patients at risk of severe mental health problems and/or suicide attempts, and allowed proper referral to psychiatric assessment and mental health interventions. Further research is necessary to assess the effectiveness of these mental health interventions in the long term.


Special thanks to the Psychosocial Team of CIENI/INER in Mexico City: Uriel Conteras-Osorno, Graciela Guzmán-Valdez, Francisco J. Quezada-Juárez.


Aguilar García-Iturrospe, E. J., Hidalgo-Montesinos, M. D., Cano-García, R., López-Manzano, J. C., Campillo-Agusti, M., & Hernández-Martínez, M. (1995). Estudio prospectivo de la desesperanza en pacientes psicóticos: Características psicométricas de la Escala de Desesperanza de Beck. Anales de Psiquiatría, 11(4), 121-125. [ Links ]

Beck, A., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42(6), 861–865. [ Links ]

Córdova-Osnaya, M. & Rosales-Pérez, J. C. (2011). Consistencia interna y estructura factorial de la Escala de Desesperanza de Beck en estudiantes mexicanos. Revista de Psicología, 29(2), 289-309. [ Links ]

Costas-González, M., Prado-Robles, V. & Crespo-Iglesias, J. M. (2013). Ansiedad y depresión entre los pacientes hospitalizados en el complejo hospitalario de Ferrol. Cuadernos de Medicina Psicosomática, 107, 16-22. [ Links ]

Ferrando, L., Bobes, J., & Gibert, J. (2000). MINI International Neuropsychiatric Interview. Versión en español 5.0.0. Instituto IAP. [ Links ]

Garcia-Capitão, C., Finotelli, J., & Santos de Macena, C. (2011). Evaluation of depression and anxiety on HIV/AIDS inpatient. Journal of AIDS and HIV Research, 3(12), 240-246. [ Links ]

Govender, R. D., & Schlebusch, L. (2012). Hopelessness, depression and suicidal ideation in HIV-positive persons. South African Journal of Psychiatry, 18(1), 17-21. [ Links ]

Grau, A., Comas, P., Suñer, R., Peláez, E., Sala, L., & Planas, M. (2007). Evolución de la ansiedad y la depresión detectada durante la hospitalización en un servicio de Medicina Interna. Anales de Medicina Interna, 24(5), 212-216. [ Links ]

Kathol, R. G., & Wenzel, R. P. (1992). Natural history of symptoms of depression and anxiety during inpatient treatment on general medicine wards. Journal of General Internal Medicine, 7(3), 287-293. [ Links ]

Nogueda-Orozco, M. J, Pérez-Terán, B., Barrientos-Casarrubias, V., Robles-García, R., & Sierra-Madero, J. G. (2013). Escala de Ansiedad y Depresión Hospitalaria (HADS): Validación en pacientes mexicanos con infección por VIH. Psicología Iberoamericana, 21(2), 29-37. [ Links ]

Nogueira-Campos, L., De Fátima-Bonolo, P. & Crosland-Guimaraes, M. D. (2006). Anxiety and depression assessment prior to initiating antiretroviral treatment in Brazil. AIDS Care, 18(6), 529-536. [ Links ]

Perdices, M., Dunbar, N., Grunseit, A., Hall, W., & Cooper, D. (1992). Anxiety, depression and HIV related symptomatology across the spectrum of HIV disease. Australian & New Zealand Journal of Psychiatry, 26(4), 560-566. [ Links ]

Plutchik, R., van Praag, H. M., Conte, H. R., & Picard, S. (1989). Correlates of suicide and violence risk: The Suicide Risk Measure. Comprehensive Psychiatry, 30(4), 296-302. [ Links ]

Rothenhäusler, H. B. (2006). Mental disorders in general hospital patients. Psychiatria Danubina, 18(3-4), 183-192. [ Links ]

Rubio, G., Montero, I., Jáuregui, J., Villanueva, R., Casado, M. A., Marín, J. J., et al. (1998). Validación de la escala de riesgo suicida de Plutchik en población española. Archivos de Neurobiología, 61(2), 143-152. [ Links ]

Vargas-Mendoza, J. E., Cervantes-Ramírez, M., & Aguilar-Morales, J. E. (2009). Estrategias de afrontamiento del SIDA en pacientes diagnosticados como seropositivos. Psicología y Salud, 19(2), 215-221. [ Links ]

Wolff, C., Alvarado, R., & Wolff, M. (2010). Prevalencia, factores de riesgo y manejo de la depresión en pacientes con infección por VIH: Revisión de la literatura. Revista Chilena de Infectología, 27(1), 65-74. [ Links ]

Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361-370. [ Links ]

FinancingThis study was carried out with funds from the Equity and Gender Commission of the LX-LXI legislatures and the Commission for Gender Equality of the LXII legislature, the Chamber of Deputies of Mexico.

Received: October 12, 2016; Revised: January 25, 2017; Accepted: January 25, 2017

Correspondence: Dra. Evelyn Rodríguez-Estrada. Departamento de Investigación de Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas. Calzada de Tlalpan 4502, 14080 Ciudad de México. Phone: +52 (55) 5666-7985 ext. 171. E-mail:

Conflict of interests

Dr. Evelyn Rodríguez-Estrada is a speaker for Pfizer Mexico. The rest of the authors do not have any conflict of interests to disclose.

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