Soc Psychiatry Psychiatr Epidemiol (1998) 33: 230234

Springer-Verlag 1998

ORIGINAL PAPER

P. Cochand P. Bovet

HIV infection and suicide risk: an epidemiological inquiry among male homosexuals in Switzerland

Accepted: 25 July 1997

Abstract Conicting results have been published about suicidality among HIV+ subjects; part of the alleged increased risk may be linked to premorbid risk factors such as drug addiction and homosexuality. In order to cope with these confounding factors, we assessed the degree of suicidal ideation in a sample of Swiss male homo- and bisexuals, comparing HIVA and HIV+ subjects. A total of 164 subjects returned a self-administered, home-completed questionnaire, which had been circulated among homosexuals in the French speaking part of Switzerland. Suicidal ideation was assessed through Po ldinger's scale. Serostatus was known for 149 subjects, among whom 65 were HIV+. A high rate of suicide attempts was found among homosexuals, both HIVA and HIV+. Scores on Po ldinger's scale are signicantly, though moderately, higher among HIV+ subjects, and this nding seems to be a direct consequence of HIV infection.

Introduction
It is generally acknowledged that patients with chronic or lethal disease and/or diseases aecting the central nervous system (CNS), such as cancer patients (Allebeck et al. 1989; Fox et al. 1982; Mackenzie and Popkin 1987; Marshall et al. 1983; Whitlok 1978), kidney-dialysis patients (Abram et al. 1971) or those suering with Huntington's chorea (Mackenzie and Popkin 1987) are at higher risk for committing suicide. AIDS is chronic, lethal and may heavily aect the CNS; it has thus been suggested that it may lead to increased suicidality.

P. Cochand P. Bovet Department of Adult Psychiatry, University of Lausanne, Lausanne, Switzerland P. Cochand (8) DAMPS, CHUV, CH-1011 Lausanne, Switzerland

The results of several retrospective epidemiological inquiries indicate such an elevated risk (Alfonso et al. 1994; Brown and Rundell 1989; Frierson and Lippmann 1988; Gala et al. 1992; Glass 1988; Kizer et al. 1988; Marzuk et al. 1988; Plott et al. 1989; Rajs and Fugelstad 1992). Marzuk et al. (1988), for example, found suicidality in New York male AIDS patients was 36 times greater than the level found in the general population of et al. (1992) found New York men aged 2059, and Cote the level to be 7.4 greater in a US national assessment among men. Catalan et al. (1995) report that seropositivity enhances the risk of suicide attempts. There is, however, some counterevidence. Parasuicide has not been found to be elevated among AIDS patients by Holland and Tross (1985). McKegney and his collaborators (McKegney and O'Dowd 1992; O'Dowd et al. 1993) found increased suicidality among HIV+ patients, but not among AIDS patients, compared to the general population. It has been pointed out (Frierson and Lippmann 1988; Gala et al. 1992) that HIV+ and AIDS patients have elevated premorbid risk factors for suicide and parasuicide, hindering comparisons based on the general population. Schneider et al. (1991) did not nd quantitative dierences in suicide ideation between HIV+ and HIVA gays and bisexuals. Perry et al. (1990) found an overall increased prevalence of suicide ideation among blood testing attenders, without dierences between HIV+ and HIVA subjects. It has long been considered that homosexuals in general are at higher suicide risk than the general population (Bell and Weinberg 1978; Harry 1983; Remafedi 1987; Roesler and Deisher 1972; Saghir et al. 1970). However, this claim has more recently been questioned (Buhrich and Loke 1988; Kourany 1987; Rich et al. 1986). A higher prevalence of suicidality among drug addicts is less controversial, and appears to be unanimously acknowledged (Allebeck and Allgulander 1990; Engstro m et al. 1991; Tunving 1988). In view of these considerations, it seems prudent, when evaluating the hypothetical inuence of HIV infection on suicidality, to avoid comparisons of high-risk

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samples with the general population, and to avoid a selection of high-risk population comprising both homosexuals and drug-addicts. We thus restricted our inquiry to male homosexuals and bisexuals, because they are the group with the highest prevalence of HIV infection in Switzerland (Bulletin OFSP 1993).

Results
Questionnaires were returned by 164 men self-dened as homo- or bisexuals. The mean age of the respondents is 36.4 (median 34, range 2266) years. Eighty percent are Swiss citizens, and two-thirds of the foreigners have been living in Switzerland for more than 10 years; 50% live in one of the main cities of Switzerland. Regarding living arrangements: 88% have never been married; 46% live alone, 35% with their homosexual partner, 9% with friends, 7% with their family and 3% with a heterosexual partner. Thirty percent have completed university (three times more than in the general Swiss population); 77% are regularly employed, 17% are on unemployment benet and 6% on long-term disability pensions due to disease. Respondents from the HIV Consultation Unit and the ``snowball'' technique do not dier signicantly on demographic data, with the exception of age. The rst group is on average 2 years older, which can be explained by the higher proportion, in that group, of HIV+ subjects (see below). Of the 164 respondents, 15 had never had an HIV blood test. Of the 149 who had been tested, 84 (54%) showed HIVA at last testing, and 65 HIV+. Of those, nine consider themselves as AIDS patients. For the latter, mean duration since discovery of seroconversion is 6.5 years, compared to 4.4 among the 56 other HIV+ subjects. We do not have data on medication received by HIV+ and AIDS patients. (At the time of the inquiry, AZT was the drug of choice, but was exclusively delivered to AIDS patients.) HIV+ subjects represent 12% of respondents through the ``snowball'' technique (the estimated prevalence of seropositivity among homosexuals in Switzerland is 12% [Gruet and Dubois-Arber 1993] and 85% of the respondents through the specialized Consultation Unit. No signicant dierences were found between HIVA and HIV+ subjects for socio-demographic characteristics, except for age: HIV+ subjects are on average 4.5 years older than those testing HIVA; there is non-signicant trend for HIV+ subjects to have a lower educational level and to be in non-professional jobs. With the exception of one missing answer, all HIV+ subjects are in regular contact with a physician, whereas only 58% of HIVA subjects regularly consult. Seventyeight percent of HIV+ subjects consider that they have been in closer contact with their relatives and proximates since being diagnosed as positive. Table 1 presents a comparison of risk factors for suicidality between HIV+ and HIVA subjects. Some of these factors are classically described in the literature (Emken et al. 1977): depressive mood, alcoholism, drug addiction, previous suicide attempts, suicide among relatives or friends, loneliness, unemployment, immigration. Others have been added specically for our population: death from AIDS of a close friend, a relative or a partner; high sexual promiscuity, dened as six or more partners during the last year; and lack of accep-

Method
During a 6-month period (October 1992 to March 1993), we circulated 574 anonymous structured questionnaires among men living in the French speaking part of Switzerland and dening themselves as homo- or bisexuals. In all, 374 questionnaires were given out through the so-called ``snowball'' technique (where a group of subjects distributes copies of the questionnaire to others, who then pass some on, and so on) and 200 were given to outpatients attending the HIV Consultation Unit of the University Hospital of Lausanne, which was at that time the only specialized medical facility in the area. The distribution through the HIV Consultation Unit aimed at reaching a sucient number of HIV+ subjects in our sample. It must be mentioned that some patients attending the Consultation are HIVA, because for research purposes the Consultation oers a follow-up to non-infected high-risk subjects. Subjects were asked to complete the questionnaire at home and to send it back to the principal investigator through pre-paid postage. A total of 164 questionnaires (28%) were completed and returned (27% of those distributed through ``snowball'', and 31% of those distributed at the HIV Consultation Unit). In order to evaluate various aspects of daily, social and sexual life, of medical support, etc. in such a specic group, we had to develop our own questionnaire. We incorporated the CAGE questionnaire (Mayeld et al. 1974) to screen for alcohol consumption, as well as Po ldinger's self-rating scale for suicide risk (Po ldinger 1983). This scale has been used in several studies in Switzerland (Po ldinger 1968, 1980; Po ldinger and Sonneck 1980). It was translated from German into French by Po ldinger himself. This scale comprises 16 unweighted questions focusing on suicide ideation, depressive mood and widely accepted risk or protective factors for suicidal behavior, such as previous suicide attempt or living with one's family (see Appendix). It rates from 0 (lowest risk) to 16. Socio-demographic data were assessed through the same questions as those used in 1992 by the Institute for Preventive Medicine of Lausanne University in its national descriptive epidemiological inquiry on male homosexuals living in Switzerland (Gruet and Dubois-Arber 1993). The use of an anonymous, self-administered, home-completed questionnaire inevitably leads to some limitations: several questionnaires were only partly completed, and for the assessment of some important characteristics such as depressive mood and drug addiction we had to rely entirely on the subjects' self-description. This holds true for the assessment of whether the HIV+ subjects had ever been symptomatic for AIDS; for that reason, our analysis does not dierentiate AIDS patients from other HIV+ subjects. Time elapsed since the discovery of seroconversion was not taken into consideration, as it seems that the illness progression in HIV+ patients does not increase the degree of depression and anxiety (Rabkin et al. 1997). We used classical non-parametric tests for statistical analysis (two-tailed chi-square, Fisher's exact probability test, MannWhitney or Kruskal-Wallis rank tests). Findings were considered as signicant at P<0.05. In order to have a description of their interrelations, we made a correspondence analysis (Lebart et al. 1977) of the most important independent variables: age, educational level, professional achievement, unemployment, CAGE scores and results of blood testing for HIV. Scores from Po ldinger's scale were projected on the orthogonal plane of the rst two factors.

232 Table 1 Comparison of risk factors for suicidality between HIV+ (N = 84) and HIVA (N = 65) subjects HIVA (%) Depressive mood CAGE score 2 Drug addiction Previous suicide attempt Living alone Lack of friends Foreigner living in Switzerland for less than 5 years Long term inability to work due to illness Unemployment benet for more than 6 months Death from AIDS of partner, close friend or relative Sexual promiscuity Homosexuality not accepted by parents
a

HIV+ (%) 12 16 3 18 40 11 5 14 12 48 33 22

Signicancea NS P < 0.02 *NS NS NS *P < 0.02 *NS *P < 0.01 NS P < 0.05 NS NS

11 30 5 26 53 1 7 1 11 31 40 23

Calculated by the two-tailed chi-square test or Fisher's exact test (asterisked)

tance of the subject's homosexuality by his parents. As previously stated, the assessment of depressive mood, alcoholism and drug addiction had to rely exclusively on the subject's statements. Depression was assessed (a) through four items of the Po ldinger's scale (see Appendix Q9-12) and (b) through the specic question: ``During past weeks, have you been (1) in your usual mood, (2) slightly depressed, (3) very depressed, (4) very depressed with suicidal ideas?''. Subjects were rated as depressed if they scored 3 or 4 on Po ldinger's subscale or if they answered (3) or (4) to the specic question. Our decision to assess depression through such an unusual double procedure was taken in order to cut the number of nonrespondents. Correlation between responses to the two sets of questions is high (91.2%) for the 125 subjects who answered both sets. Alcoholism was assessed through the CAGE questionnaire, with a cut-o point of 2. Subjects were considered as drug addicts if they mentioned regular use of heroin, methadone or cocaine. In summary, HIV+ subjects are older, have a lower alcohol consumption, fewer friends and have more often been aected by a proximate's death from AIDS than HIV subjects. Moreover, as could be expected, they are more often on sickness-disability pensions. Concerning alcohol consumption, it is worth noting that 70% of HIV+ subjects mention that they spontaneously lowered their alcohol intake when they were diagnosed positive for HIV.

Overall, 22.7% of sampled subjects had made at least one suicide attempt. This is a high proportion. Unfortunately there are no epidemiological data for Switzerland that could provide a point of comparison. There are no signicant dierences between HIV+ and HIVA subjects. The score on Po ldinger's scale for suicidality was assessed for 144 subjects (133 with known serostatus). Twenty subjects did not answer (3% of whom were HIV+, 17% HIVA, 27% of unknown serostatus), some of them stating through handwritten annotations that they refused to link suicidality and homosexuality. The overall mean score is 4.15 (range 015; median 3; mode 2). There is no signicant dierence between HIVA and HIV+ subjects. However, two factors may lead to an articial erasing of dierences: rst, suicidality is known to be age dependent, with a peak of suicidality during the rst half of the life cycle, i.e. before the age of 44 (Diekstra 1993); this is observable in our sample, in which the 76 subjects born 1958 and after have a (nonsignicantly) higher score on Po ldinger's scale than the 63 older subjects (for 5 subjects, we do not have data on age). In our sample, HIV+ subjects are signicantly older than HIVA ones. A second confounding factor may be that the projection of Po ldinger's score on the correspondence space has a U shape, and very low scores (0 and 1) project near the score 6. It could be hypothesized that some of the 14 subjects (7 HIV+; 6

Table 2 Scores on Po ldinger's scale with and without correction for age and very low scores

HIVA N Mean Po ldinger's score 4.01 3.60 4.30 3.91

HIV+ N Mean Po ldinger's score 4.46 4.47 4.89 4.95

Signicance (Mann-Whitney)

Without corrections After elimination of subjects born 1964 After elimination of scores 1 After both corrections

70 47 64 42

63 49 56 43

NS P < 0.05 P < 0.05 P < 0.01

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HIVA; 1 unknown serostatus) with very low scores concealed or denied any suicide ideation. We thus recalculated Po ldinger's scores (1) after elimination of the younger subjects (born 1964 and later); (2) after elimination of scores 1; and (3) by applying both corrections. Table 2 presents the results. Whereas row scores do not show a signicant increase in suicidal risk among HIV+ compared to HIVA subjects, each of the corrections (and a fortiori both) lead, despite reduced sample size, to a signicant difference.

Discussion
The questionnaires were collected in such a way as to preclude any claim of the sample being representative of male homosexuals living in Switzerland. Moreover, two dierent techniques were used to sample the majority of HIVA, respectively HIV+, subjects. However, this sampling bias is not reected in socio-demographic characteristics, which do not dier between HIVA and HIV+ subjects. In addition, whenever possible, we compared our sample to the national descriptive assessment conducted by the Institute for Preventive Medicine of Lausanne University (Gruet and DuboisArber 1993). In the latter, questionnaires were released through specialized newspapers and reviews for homosexuals, through gay associations and in saunas. No dierences in demographic data appear between the samples, except for the proportion of foreigners; gures of the present sample (20%) are closer to the general Swiss proportion (18%) than are the gures in the national assessment (12%). The high proportion of subjects with university degrees is found in both samples, as well as in several French inquiries (Gruet and DuboisArber 1995; Pollak 1992). However, dierences between the two samples are found in sexual behaviour: our sample has less sexual promiscuity, less cruising in anonymous places (public parks and toilets) and fewer bisexuals. It can thus be considered as slightly more stable than the national assessment's sample. Meanwhile, in the absence of any other point of reference, nothing can be said on its representativity. Our nding of a high overall cumulated risk of suicide attempt in this sample of male homosexuals is in agreement with some other studies (Bell and Weinberg 1978; Harry 1983; Remafedi 1987; Roesler and Deisher 1972; Saghir et al. 1970). It should, however, be taken with two caveats: (1) the occurrence of suicide attempt was left to the subject's own assessment, without any operational denition; (2) the representativity of our sample is not ascertained. HIV+ subjects are at signicantly higher suicide risk than HIVA subjects. In our view, this dierence is a direct consequence of serological status, as we do not

think that confounding factors may be invoked. It is found after age correction between the two groups. Lower alcohol consumption, social isolation and inability to work, which are more frequent in the HIV+ group, are consequences of HIV infection; the direction of causality between HIV positivity and the death from AIDS of proximates is more ambiguous, but this factor is not likely to explain the dierence in Po ldinger's scores. No other independent variable shows any signicant dierence between the two groups. In particular, the prevalence of drug addiction, an important confounding factor, is low in both subgroups. It has, however, to be stressed that the dierence in suicidality between the two groups is weak, and that the mean score of HIV+ subjects does not reach a high level of severity. Social isolation and discrimination are among the factors that have been suspected as increasing suicidality among HIV+ subjects. It is, however, important to distinguish social isolation from social discrimination. HIV+ subjects have fewer social relationships (fewer friends and more absence from work), but this does not mean that they feel discriminated against. In our sample, they do not live more often alone, they feel close to their relatives and are almost unanimously satised with the conditions of medical help and counseling they receive. In our opinion, this represents a protective factor in relation to suicidality, though it has not been measured in our study. It is probably one of the results of the Swiss de ral de campaign led by the health authorities (Oce Fe Publique), which has been internationally recla Sante ognized as greatly improving prevention of HIV infection and reducing discrimination against HIV+ subjects (Gromyko et al. 1992).

Appendix
Po ldinger's suicidality scale 1. Have you been thinking lately of putting an end to your life? 2. Often? 3. Did you think of it without really wanting it. Did the suicidal thoughts come by themselves? 4. Have you been thinking of any practical way to do it? 5. Have you been preparing anything to this purpose? 6. Did you talk to anybody about those ideas? 7. Have you ever tried to kill yourself? 8. Has anybody committed suicide in your family, among your friends or acquaintances? 9. Does your situation appear hopeless to you? 10. Is it dicult to think of anything other than your problems? 11. Do you see more rarely your relatives and friends lately? 12. Are you still interested in what is happening in your profession and around you in general? 13. Did you have the opportunity to talk freely and intimately of your problems to anybody? 14. Do you live with your family or friends? 15. Do you have strong family ties, do you have important professional responsibilities? 16. Are you member of a religious community?

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