Copyright Blackwell Munksgaard 2003

Acta Psychiatr Scand 2003: 107: 4144

Printed in UK. All rights reserved

ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0001-690X

Characteristics of HIV patients who

attempt suicide
Roy A. Characteristics of HIV patients who attempt suicide.
Acta Psychiatr Scand 2003: 107: 4144. Blackwell Munksgaard 2003.
Objective: To examine the risk factors for suicidal behaviour in human
immunodeciency virus (HIV) positive patients.
Method: HIV substance dependent positive patients who had
attempted suicide were compared with HIV substance dependent
positive patients who had never attempted suicide for suicide risk
factors.
Results: Among the 149 HIV positive patients examined almost half
had attempted suicide. Signicantly more HIV positive patients who
had attempted suicide were female. Attempters were signicantly
younger than non-attempters. Signicantly more of the attempters had
a family history of suicidal behaviour. Attempters also reported
signicantly more childhood trauma, scored signicantly higher for
neuroticism, had experienced signicantly more comorbidity with
depression, and more of them had received antidepressant medication.
Conclusion: These data suggest that both distal and proximal risk
factors are involved in suicidal behaviour in HIV positive substance
dependent patients.

Introduction

Adults infected with the human immunodeciency

virus (HIV) are at increased risk of suicide (1). For
example, Marzuk et al. (2) found that almost 9%
of all suicide victims in New York City in the early
1990s were HIV positive and estimated that positive HIV individuals had a twofold higher risk for
suicide than the general New York City population. Other studies have reported a 736-fold
increased risk of suicide in HIV positive individuals
(27).
Recently reviewing the scant literature on suicidal behaviour in individuals with HIV, Hughes
and Kleespies (8) concluded that it was unclear
what factors contribute to pathways to suicide in
HIV patients. Therefore, it was decided to compare
HIV substance dependent patients who had attempted suicide with HIV substance dependent
patients who had never attempted suicide on risk
factors for suicidal behaviour.
Aims of the study

The aim of the study was to compare the two

groups for distal risk factors thought to predispose

A. Roy
Psychiatry Service 116A, Department of Veterans
Affairs, New Jersey Healthcare System, NJ, USA

Key words: human immunodeficiency virus; suicide;

attempt; risk; factors
Alec Roy, Psychiatry Service 116 A, Department of
Veterans Affairs, 385 Tremont Avenue, East Orange, NJ
07018, USA
E-mail: alec.roy@med.va.gov
Accepted for publication June 25, 2002

to suicidal behaviour when the individual experiences a proximal or triggering risk factor like
being HIV positive. Specically, we hypothesized
that signicantly more of the HIV positive attempters would have a family history of suicidal
behaviour, would report more childhood trauma,
would have higher neuroticism scores, and would
have had more comorbidity with depression.
Material and methods

A series of 149 HIV positive substance dependent

patients were examined; 111 were seen in the
Substance Abuse Treatment Program at the
Department of Veterans Aairs, New Jersey
Healthcare System, East Orange Campus and 38
were seen in a community mental health center,
East Orange, New Jersey. Inclusion criteria were
that the patient had been diagnosed as HIV
positive and met DSM-IV criteria for substance
dependence. Exclusion criteria were a lifetime
history of schizophrenia or other psychosis or
mental retardation.
A semistructured interview was conducted about
sociodemographic variables; lifetime alcohol,
heroin and or cocaine dependence meeting
41

Roy
DSM-IV criteria; lifetime history of any attempts
at suicide, and about suicidal behaviour in rst and
second degree relatives. The information from the
patient was supplemented by collateral information from mental health program sta, medical
records, the program internist and physicians
assistant and, where possible, from previous treating mental health professionals. A suicide attempt
was dened as a self-destructive act with some
intent to end ones life that was not self-mutilatory
in nature.
Patients were also interviewed with the depression section of the Structured Clinical Interview for
DSM-IV (10) to determine whether or not there
was a lifetime history of a major depressive episode
(MDE) meeting DSM-IV criteria (MDE criteria
were conservatively used as more depressive symptoms are required than in some other DSM-IV
mood disorder diagnoses, i.e. substance-induced
mood disorder or dysthymic disorder). Patients
completed two questionnaires: the Eysenck Personality Questionnaire (EPQ) (11) which yields
neuroticism, extraversion, psychoticism and lie
scores; and the Childhood Trauma Questionnaire
(CTQ) (12) )34-item version which yields scores
for emotional abuse, physical abuse, sexual abuse,
emotional neglect, physical neglect, and a weighted
total score. The CTQ has been shown to have high
reliability and validity (12, 13). After complete
description of the study to the subjects, written
informed consent was obtained. Not all patients
completed both questionnaires.
In the statistical analysis, Students t and chisquare tests were used. The level of statistical
signicance used was P < 0.05.

Table 1. Sociodemographic data of HIV positive patients who had or had never
attempted suicide

Age in years
Sex
Male
Female
Ethnic background
AfricanAmerican
Hispanic
Caucasian
Personal status
Married
Single
Separated divorced or
widowed
Employment status
Employed
Unemployed

Attempted suicide
(n 66)

Never attempted suicide

(n 83)

42.1 6.3

46.3 5.8a

46
20

73
10b

49
6
11

66
10
7

6
34
26

15
35
33

6
60

9
74

Attempters were significantly younger (t 4.2, d.f. 147, P < 0.0001).

Significantly more of the suicide attempters were female (v2 6.52, d.f. l,
P < 0.01).

received antidepressant medication (49 of 66 vs. 33

of 83, v2 16.3, d.f. l, P < 0.0001). Signicantly more of the attempters had a family history
of suicidal behaviour (17 of 66 vs. 10 of 83,
v2 3.78, d.f. 1, P < 0.05). There was no
signicant dierence for a lifetime history of
alcohol dependence (26 of 66 vs. 25 of 83, NS).
HIV positive patients who had attempted suicide
had signicantly higher scores on the CTQ for
childhood emotional abuse, physical abuse, sexual
abuse, emotional neglect and physical neglect
(Table 2). HIV positive attempters also had significantly higher neuroticism scores on the EPQ
(Table 3).

Results

The sample consisted of 149 HIV positive patients,

66 (44.3%) had attempted suicide and 83 (55.7%)
had not. Signicantly more of those who had
attempted suicide were female (P < 0.01, Table 1).
Also, patients who had attempted suicide were
signicantly younger than patients who had never
attempted suicide (P < 0.0001, Table 1). There
were no signicant dierences for ethnic background, employment status or marital status
(Table 1). Of the 66 patients, 51 who had attempted suicide had a primary substance dependence
diagnosis of opiate dependence and 15 cocaine
dependence compared with 67 and 16 of 83
patients who had never attempted suicide (NS).
Signicantly more of the patients who had
attempted suicide had a lifetime history of a
depressive episode (59 of 66 vs. 37 of 83,
v2 30.3, d.f. l, P < 0.0001) and of having
42

Discussion

In the present study signicantly more HIV positive patients who had attempted suicide were
female, had a family history of suicidal behaviour,
had had a depressive episode, and had received
antidepressant medication. HIV positive patients
who had attempted suicide were signicantly
younger than those who had never attempted
suicide. They also had signicantly higher childhood trauma and neuroticism scores than HIV
patients who had never attempted suicide.
The most generally accepted model of suicidal
behaviour is the risk factor model (9). Suicidal
behaviour frequently involves an interaction
between distal risk factors eecting the threshold
for attempting suicide and proximal or triggering
factors like being HIV positive and or depressed
that precipitate the attempt. In the present study

Suicidal behaviour of HIV positive patients

Table 2. HIV positive patients who had or had not
attempted suicide compared for their scores on the
Childhood Trauma Questionnaire

Childhood trauma
variable

Attempted suicide
(n 58)

Emotional abuse
Physical abuse
Sexual abuse
Emotional neglect
Physical neglect
Weighted total

14.6
13.4
13.8
30.5
18.3
13.5

6.1
5.4
8.4
10.8
6.8
4.4

Never attempted suicide

(n 63)
10.5
9.7
9.2
25.6
14.8
10.0

4.8
4.2
5.0
10.5
5.3
3.2

Significance
(d.f. 119)
t 4.1, P < 0.0001
t 4.3, P < 0.0001
t 3.7, P < 0.0003
t 2.6, P < 0.01
t 3.2, P < 0.002
t 4.9, P < 0.0001

Values are expressed as mean SD.

Table 3. HIV positive patients who had or had not
attempted suicide compared for their scores on
personality variables

Personality variable

Attempted suicide
(n 25)

Eysenck scores
Psychoticism
Neuroticism
Extraversion
Lie

5.8
17.6
10.1
7.3

2.6
3.4
4.1
4.3

Never attempted
suicide
(n 47)

5.5
14.2
10.7
8.8

2.7
5.4
5.3
4.2

Significance
(d.f. 68)

NS
t 2.85, P < 0.006
NS
NS

Values are expressed as mean SD.

there were signicant dierences between the two

groups for three distal suicide risk factors. First,
signicantly more of the attempters had a family
history of suicidal behaviour. Secondly, HIV positive patients who had attempted suicide reported
signicantly more childhood emotional abuse,
physical abuse, sexual abuse, emotional neglect,
and physical neglect. Childhood trauma have been
shown to be a risk factor for attempted suicide
(reviewed in 14). Thirdly, HIV positive patients
who had attempted suicide were signicantly more
neurotic. Neuroticism has been shown to be
associated with suicidal behaviour in general (reviewed in 15). Murphy et al. (16) found that opiate
dependent patients who had attempted suicide had
signicantly higher neuroticism scores and Kosten
and Rounsaville (17) found that neuroticism predicted suicidality during a 2.5-year follow-up of
opiod addicts. Similarly a recent longitudinal study
showed that individuals who had attempted suicide
by 21 years of age had signicantly higher neuroticism scores at 14 years of age (18). The results of
that study also suggested that early neuroticism
was related to later psychiatric disorder, particularly depression, which in turn was associated with
suicidal behaviour.
Depressive disorders are prevalent among HIV
positive patients. For example, a recent study
screened 2864 HIV positive adults and found that
nearly half of the sample screened positive for a
psychiatric disorder during the previous
12 months (19). Thirty-six percent of the population screened positive for major depression and
26.5% for dysthymia. These data are relevant as
the present study suggests that depression is a

risk factor for suicidal behaviour in HIV positive

patients. Not only did signicantly more of our
HIV attempters have a history of depression
but signicantly more of them had also received
antidepressant medication. An Italian study, from
an infectious diseases clinic, similarly reported that
HIV positive patients with a past psychiatric
history showed an increased risk for deliberate
self-harm (20).
A limitation of the present study is that the
sample was of HIV positive patients with a lifetime
history of substance dependence. The majority
were being treated and thus referral factors might
partly explain that 44.3% had attempted suicide.
This may limit the generalizability of the ndings
although a large percentage of HIV patients are
substance abusers. For example, a recent survey
found that 61.4% of 2 314 000 American adults
under care for HIV had used mental health or
substance abuse services in the previous 6 months
(21). Another limitation is that we did not have
systematic information on HIV-related brain
pathology. However, we did have Addiction
Severity Index (ASI) interview data on 37 of the
patients and there was no signicant dierence on
the ASI medical severity composite scores between
patients who had (n 15) or had not (n 22)
attempted suicide (mean SD 0.51 0.08 vs.
0.60 0.06, d.f. 35, t 0.91, NS). In this
regard it is noteworthy that Marzuk et al. (9)
found that over two-third of their HIV positive
suicide victims showed no HIV-related pathology
or AIDS-indicator conditions at autopsy.
In summary, HIV substance dependent patients
who had attempted suicide had more risk factors
43

Roy
for suicidal behaviour than HIV patients who had
never attempted suicide. Risk factors for suicidal
behaviour in HIV patients may be interactive. The
diagnosis of HIV positive status may be a
proximal risk factor which may lead to suicidal
behaviour in the presence of predisposing distal
risk factors like childhood trauma or neuroticism
which may also predispose to the development
of depression and may then become an additional
precipitating proximal factor. The diagnosis and
treatment of depression is an important aspect of
suicide prevention and thus it is noteworthy that
antidepressant medication has been found to
eectively treat depressed HIV positive patients
(22).
Acknowledgements
Supported by grant R01 DA 10336-02 from the National
Institute of Drug Abuse, National Institutes of Health,
Bethesda, MD, USA.

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