Subjective Memory Complaints of HIV / AIDS Patients in Iran : Relationships with Mood , Social Support , Medical Symptoms and Substance Abuse

Introduction: Several studies suggested that subjective memory complaints in HIV-infected patients are influenced by factors the same as mood, social support and medical symptoms. The aim of this research was to investigate the relationship between depression, anxiety, social support and substance abuse with memory complaints in HIV/AIDS patients. Method: To accomplish this goal, in a correlation study, 220 Iranian adults (146 males and 74 females) selected from the Voluntary Counseling and Testing (VCT) Center in Shiraz in 2012, completed these measures: Depression Anxiety Stress Scale (DASS-21), The Patient’s Assessment of Own Functioning Inventory (PAOFI), Quality of Relationship Inventory (QRI) and Rey Auditory-Verbal Learning Test (RAVLT). Analyses were performed using the SPSS-16. Results: Results showed that better performance of memory, was associated with being female, higher levels of education and lower years of substance abuse. Also, multiple regression analysis revealed that anxiety, substance abuse and depression can explain 43 percent of subjective memory complaint. Anxiety had the most contribution in predicting complaints and after that, substance abuse was more important. Objective memory performance had a significant correlation with complaints but was not a significant predictor of subjective memory complaints. There was no relationship between subjective complaints and social support. Conclusion: According to results, it seems that in treatment plans for these patients, focusing on emotional problems, to improving subjective complaints, is necessary.


Introduction
HIV infection has studied from many aspects.One of that is effect on brain and cognitive functions.Researches have shown that HIV infection and it's progress stage (AIDS) has appearances such as cognitive impairments (Selnes et al., 1995;Castellon et al., 1998) and behavioral symptoms (Navia & Price 1987;Odiase et al., 2007;Obiabo et al., 2011).Problems based on HIV/AIDS patients daily functions report, have examined in many studies and complaints such as attention and concentration problems, forgetfulness, and difficulties with 'multi-tasking were the common subjective cognitive symptoms in this Group (Maj et al., 1994;Mehta et al., 1996;Atkins et al., 2010).Both diagnosis and treatment decisions are affected by subjective cognitive complaints that HIV patients report from daily life and clinicians rely on these as an important source of information (Carter et al., 2003).
HIV associated neurocognitive disorders (HAND) include a range of mild forms such as asymptomatic neurocognitive impairment (ANI), mild neurocognitive disorder (MND) to the gloss forms such as HIV-associated dementia (HAD) (Obiabo, Ogunrin, & Ogun, 2011).HIV associated neurocognitive disorders (HAND) infection is frequently diagnosed with respect to patients' subjective complaints from their everyday life.Nevertheless, a number of studies conducted in Western countries indicate the affective factors on these complaints (Au et al., 2008).For example, Sadek et al., (2006) reported that in HIV infected and other populations, subjective complaints of daily functioning, notably cognitive complaints may be related to the depressive symptoms.The effects of affective disorders including depression and anxiety and other factors, like social support have been analyzed in the complaints.The results showed that most of the complaints, notably memory complaints were related to these effects (Chan et al., 2007;Au, et al 2008;Atkins, et al., 2010).Kizilbash et al., (2002) suggested other negative effects of depression and anxiety on cognitive decline, for example retrieval of new information, immediate recall, and amount (but not rate) of acquisition deficits.According to the results of the study by Cholewinska & Szymanska (2009), Neurological and psychiatric disorders such as dementia and depression may be making difficult to understand and follow the proper treatment plan for these patients and lead directly to poor adherence to antiretroviral therapy.Another factor, which is related to depression, social support, has studied recently.Atkins et al., (2010), showed that increased levels of cognitive symptom burden resulted in depression (P<0.05) while the decreased levels of cognitive symptom burden resulted in high social support (P<0.01) and high educational levels (P<0.05).Chan et al. (2007) claims that depressive mood plays a crucial factor that directly affects the patient's subjective memory complaints.Moreover, he showed that social support as a mediating variable indirectly led to the depressive mood.Therefore, the memory complaints may show the mood disturbance and social support may be effective in ameliorating depressive mood and these complaints.Au et al. (2008), showed the significant relationship between the subjective memory complaints, anxiety and depression.However, he indicated that there was no relationship between these complaints and objective memory test measures.Therefore, the BDI cognitive-affective score was considered as the most significant predictor of subjective memory complaints on the PAOF.
It is important to consider the effects of other common co-morbidities such as substance abuse in treatment plans for individuals with HIV-infection.About 44% of HIV/AIDS adults have alcohol and substance abuse disorders more than general population (Rabkin, McElhiney & Ferrando, 2004).In Iran, the majority of HIV-infection or AIDS (about 62% of reported cases) are diagnosed in injecting drug users (Razani et al., 2007).Patients who have substance abuse problems, may not follow treatments, so don't have enough outcomes (Meade et al., 2011;Tucker et al. 2004).Most researches about subjective memory complaints in HIV patients have been performed in developed countries and-no study has been done in Iran.In this study, in addition of previous variables, we investigated the importance of substance abuse on subjective memory complaints in HIV/AIDS patients to answer these questions: 1).Whether substance abuse is related with subjective memory complaints?
2).How much substance abuse can predict these complaints?

Participants
Statistical population included 220 Iranian adults (146 males and 74 females) that were selected from the Voluntary Counseling and Testing (VCT) Center in Shiraz in 2012.All participants took part in the study with satisfaction and they were paid as the reward.Inclusion criteria were being infected by HIV-1 infected and being adult between 18-50 years old.The participants who had a history of a non-HIV related neurological disorder (e.g.seizure disorder) or a medical disorder affecting the nervous system function (e.g. head trauma with more than 1-hour loss of consciousness) or central nervous system (CNS) opportunistic infection such as MS were excluded.Only 65 participants were in HIV stage (but without AIDS) (30.2%) and 150 participants had symptoms of AIDS (69.8%).Five participants were excluded due to lack of information (2.27%).

Research Instrument Cognitive complaints
The Patient's Assessment of Own Functioning Inventory-Memory subscale (PAOF-Memory; Chelune, Heaton, & Lehman, 1986) is considered as a self-report questionnaire that necessitates the participants report their experienced difficulties in neurocognitive functioning, and include memory, language and communication, sensory-perceptual and motor skills.The questionnaire is based on a six-point scale (0=almost never; 1=very infrequently; 2=once in a while; 3=fairly often; 4=very often; 5=almost always).Total score was derived from a summation of all items.This measure showed good internal consistency in this study (α= 0.93 for total scale).

Social support
Quality of Relationship Inventory-Social Support scale (QRI-Social Support; Pierce, Sarason, & Sarason, 1991), measures three aspects reflecting quality of an identified relationship.Social support is defined as how a partner, listen and provide help with problems or to engage in social activity.Conflict is defined as negative emotions, such as anger, guilt, and mistrust related to interpersonal interactions with the spouse or parents.Depth of relationship is defined as the significance of the relationship in a participant's life.Participants responded to each statement on a Likert-type that ranged from 1 (not at all) to 4 (very much) about their spouse, parents and the friends (Gharehbaghy, 2011).Pierce and colleagues reported alpha coefficients about 0.83 to 0.91.In this study we used social support aspect with alpha coefficient 0.70.

Depression and Anxiety
Depression Anxiety Stress Scale (DASS;Lovibond, & Lovibond, 1995), is a 21-item self-report questionnaire that measures the severity of common symptoms in depression, anxiety and stress.The subject is required to report symptoms in the past week.Each item is scored from 0(never) to 3(always).We used DASS with alpha coefficient 0.81(for depression) and 0.77 (for anxiety) in our study.

Objective Memory Performance
Rey Auditory -Verbal Learning Test (RAVLT; Rey, 1964;Spreen & Strauss, 1991), consists a list of 15 irrelevant words (List A), was presented orally five times and participants were asked to recall as many words as possible after each presentation of words.Then List B (other 15 irrelevant words) was presented and participants were asked to recall as many words as possible and again to recall as many words as possible from List A. After 20 minute, participants were asked to recall as many words as possible from List A. 20minutes delayed recall score used for objective memory performance (we used raw score).

Data Analysis
SPSS 16.0 was used for data analysis.Bivariate analysis was used to show the relationships between the research variables.finally, only the variables that had a significant correlation with PAOF-Memory, were included in the hierarchical linear regression analysis.

Results
The demographic characteristics of the 220 HIV/AIDS patients are shown in Table1.One hundred and thirty-six (61.81%) participants were treated with antiretroviral medications.Participants ranged in age from 24 to 54, with a mean age of 38.4.Mean education level of respondents was 7.74 years and about three quarters (78.4%) were unemployed.
Table 2 presents the descriptive data of measures.The mean depression score ofDASS-21 was 9.25 (SD_5.35), the mean anxiety score of DASS-21 was 8.68 (SD_4.76)and the mean score of social support in QRI was 42.60 (SD_1.28).Depression and anxiety were higher than normal range.The mean score on subjective memory complaints was 17.59 (SD_1.04)and higher than normal people (p=0.04).The mean score of objective memory performance was 9.34 (SD_2.85).This finding was lower than normal people (p<0.01).

Correlations among Variables
Correlations between study variables are shown in table 4. Higher levels of substance abuse were significantly associated with more subjective memory complaints (r=0.37,p<0.01).Measures of depression and anxiety were highly inter correlated.Increased frequency of complaints on PAOF-Memory, correlated positively with increased levels of anxiety and depression on DASS-21.Substance abuse had a positive correlation with age and negative correlation with gender.Increased frequency of complaints on PAOF-Memory correlated positively with increased levels of substance abuse.But, it was correlated negatively with objective memory performance measured by RAVLT20-minute Delay Recall.However, there was no significant correlation between PAOF-Memory and social support.

Prediction of Subjective Memory Complaints (PAOF-Memory)
Forward regression was carried out to evaluate the relative significance of depression, anxiety, substance abuse and objective memory performance in predicting subjective memory complaints.Five variables that correlated significantly with PAOF-Memory were entered into regression as independent variables.These included gender, mood variables including depression and anxiety scores on DASS-21 as well as the RAVLT 20-Minute Delay Recall and substance abuse.The details of the regression analysis are shown in Table 5. Gender, anxiety, substance abuse, and depression were the significant predictors for subjective memory complaints, accounting for 43% (p<0.001) of the variance.Although there was a significant correlation between the objective memory performance and the complaints, it was not a significant predictor of subjective memory complaints.

Comparison between Those Who Have Left the Drugs and Those Taking Methadone
Investigating the effects of substance abuse on the memory complaints, we compared the power of variables in two groups include the participants who have left the drug and who taking methadone now, in predicting subjective memory complaints.In the first group, depression was the only significant indicator of memory complaints (R 2 =0.20) and in methadone users, anxiety and depression were the factors could explain 27 percent of complaints.

Discussion
This study was performed in Iran, by the purpose of investigating the effects of mood, social support and substance abuse on subjective memory complaints in HIV/AIDS patients.In general, 66.4% of participants were male and 33.6%, female; which was incompatible to the situation among the HIV/AIDS population in Iran (Fars province)that 83.5% of the patients was male and 16.5% was female (Shiraz University of Medical Sciences, 2012) and this variable was controlled in analysis.
Females and high-educated people showed the high performance of memory (this is consistent with the results of Au et al., 2008) and lower years of substance abuse.There was high co-morbidity between depression and anxiety (Mineka, Watson, & Clark, 1998;Au et al., 2008;Morrison et al., 2011).Despite Au et al., 2008, increased depression and anxiety were associated with lower performance of memory.
Subjective memory complaints of the participants were associated with anxiety, substance abuse, depressive mood and their performance on objective memory test.Three variables include Anxiety, substance abuse and depression were significant indicators of subjective memory complaints and could explain 43 percent of them.
The main result of our study was that anxiety had the most contribution in predicting complaints contrast to previous researches which depression was main variable.In the next step, substance abuse was more important.These results are different from Chan et al (2007) and Au et al (2008) who showed that depressed mood and BDI Cognitive-Affective score in turn, were the most important factors to explain complaints.Two issues were considered: (1) social attitudes to HIV infection and (2) duration of disease.1-In fact, the patients are worry about nature of HIV infection, social attitudes toward this disease, family involvement, protection of friends and other people from transmission, job replacement, medical costs and others, make these people to experience stress and anxiety.Among these, social attitudes especially in a religious society, is the most important factor to make stress and anxiety, when a person is warned about HIV diagnose.2-On the other hand, confronting the HIV diagnosis and coping with problems along with, is so hard, especially in early years.Perreta et al (1996) suggested that in early stages of disease, anxiety appears with physical and psychological symptoms and with the progress, cognitive deficiency and confusion are diagnosed.In the next stages, many of patients, will experience depression and cyclothymia.Comparison of present sample and other studies, showed that about 30 percent of participants were in early stages of HIV/AIDS (less than 24 months), about 4times the previous studies, so it is possible that, in early stages of HIV infection, anxiety has more effect than depression on participants subjective evaluation about their memory function.In other words, in the early stages of the disease, anxiety is more common and over time, they accept their illness, so suffer from depression.
Substance abuse is another important variable to explain complaints.It seems that substance abuse like mood disturbances effects on the evaluation of memory functions in addicts.In addition, objective memory performance may be affected by the drug, so complaints increased with lower memory performance.We intered RAVLT score in the analysis but it was removed and couldn't predict complaints.Similar to Van Gorp, Satz, Hinkin, Selnes, Miller & et al., 1991;Moore et al., 1997;Chan et al., 2007;and Au et al., 2008, objective memory performance didn't have significant effects on subjective memory complaints in our study.Based on previous studies (Atkins et al., 2010;Chan et al., 2007), it was expected that social support had more important effect on memory complaints; but no significant relationship was found in this study.It is necessary to mention that the respondents to the QRI questionnaire, were so similar.In other words, the participants had almost the same social conditions.For example, most of them had rejected by spouse, family or friends and reported low levels of social support.So this variable had no effect, on subjective complaints.
We also investigated the factor which is more important to predict complaints among participants who had been left drug and who used methadone.Just depression in first group and both depression and anxiety in second group, were significant predictors.Richardson-Vejlgaard et al. (2009) found that there was a more significant relationship between cognitive complaints and depression than cognitive performance for both substance-abusing (SA) patients and non-clinical samples.Of course participants who had not use any drug, were not examined due to small sample size (N=10).It seems that emotional disturbances such as anxiety are more in methadone users than participants who left the drugs and memory complaints are related to these factors than memory performance.
One of the limitations of the study was the lack of consideration of the kind of drugs used by participants, that their effects on the different cognitive complaints should be investigated in future studies.Moreover, we used one measure for two variables, depression and anxiety, to decrease number of questions, but it should be solve in next researches.For future studies, more sample size is needed to identify other cognitive complaints include language, perception and higher level cognitive and intellectual function in HIV/AIDS patients in Iran.Also these complaints should be examine and verify with widespread neuropsychological instruments.In addition, patients with different social support conditions must be examine in future studies.

Table 1 .
Demographic characteristics and clinical characteristics of participants (N=220)

Table 2 .
Descriptive data of measures (N=220) a Patient's assessment of own functioning inventory; b Rey Auditory -Verbal Learning Test.

Table 3 .
Prevalence of subjective memory complaints on the PAOF-Memory

Table 6 .
Comparison between two groups