The syndemic condition of psychosocial problems related to depression among sexually transmitted infections patients

Introduction

Sexually transmitted infections (STIs) are spread predominantly by sexual contact and body fluid exchange, among which trichomonas, chlamydia, syphilis, gonorrhea, are most common globally. More than 1 million STIs are acquired every day worldwide (Rowley et al., 2019). In China, acquired immunodeficiency syndrome (AIDS), syphilis, gonorrhea are three major types of the greatest prevalence in China. And both AIDS and syphilis showed upward trends from 2004 to 2016, with an incidence of 3.97/10,000 and 31.97/10,000 in 2016, respectively (Ye, Liu & Yi, 2019). STIs patients are at high risk of HIV infections and transmissions due to unprotected sexual encounters. Meanwhile, depressive symptom rates are extremely high among STIs patients. An American study reported 39.2% of STIs patients in the survey had probable depression (Erbelding et al., 2001). In 2015, Mo et al. (2015). reported 43% probable cases of depression in Chinese female STIs patients in Hongkong, while the depressed patients accounted for nearly 4.4% and 4.2% of the world and Chinese whole population, respectively. The issue is increasingly pressing.

For STIs patients, depression and status of infection interact as both cause and effect. Researches had showed that patients with sexually transmitted infections bore heavier psychosocial burden than general population, primarily caused by poor self-image and sex-related concerns (Qi et al., 2014). Emotional impact was seen most among them. On the other hand, symptoms of depression also concerned with unprotected sexual intercourse, multiple sex partners and gave rise to a potential prevalence of STIs (Hutton et al., 2004; Shrier, Harris & Beardslee, 2002). Culture difference did not seem to break the correlation. Based on Taiwan National Health Insurance Research Database, Huang et al. (2018) conducted a retrospective study in 5,959 depression patients, among which 5.0% was later diagnosed with STIs, compared to 3.2% in control group without depression (P < 0.001).

Depression is caused by the complex interactions of pathological, social and psychosocial factors (WHO, 2020). According to previous studies, people who suffered mental health problems such as low self-esteem, loneliness, unmet social support, entrapment, defeat and dissatisfied interpersonal needs were more vulnerable to depression. Self-esteem had a close relationship with the onset, maintenance, and relapse of depression (Choi et al., 2019; Han & Kim, 2020; Sowislo & Orth, 2013). The relationship between loneliness and depression was longitudinal effect which is bidirectional but more significant with former as origin (Domènech-Abella et al., 2019). Meanwhile, social support was also significantly correlated with depression and partially mediated loneliness and depression (Liu, Gou & Zuo, 2016). The roles of defeat and entrapment in depression were first proposed by Gilbert & Allan (1998) and had been confirmed to be promising variables for the study of depression (Carvalho et al., 2013; Gilbert & Allan, 1998; Trachsel et al., 2010). The interpersonal theory of suicide had been applied in prediction of future depression with thwarted belongingness and perceived burdensomeness shown to give contribution to higher interpersonal shame and eventually led to depression (Carrera & Wei, 2017). The roles of the psychosocial factors above in the development of depression are worth exploring in patients with STIs.

STIs patients may experience multiple mental health problems that may contribute to depression vulnerability in a syndemic way. The concept of syndemic was first proposed by Singer & Clair (2003) to describe that several concurring epidemics may synergistically interact to undermine health in a certain population (Guadamuz et al., 2014; Tsai, 2018). Synergistic epidemic or syndemic effect is the aggregation of more than two concurrent or sequential epidemic or disease clusters in a population. The syndemic effect exacerbates the disease burden. The syndemic theory has become increasingly popular for policymaker and program implementers to improve population health, especially in the field of HIV treatment and prevention (Tsai, 2018). Previous studies found the combined impacts of psychosocial problems on suicide ideation in HIV+ patients (Wang et al., 2018), men who have sex with men (MSM) (Li et al., 2016) and STIs patients (Wang et al., 2020). Likewise, we hypothesized that there may be magnifying effects of the syndemic of multiple psychosocial factors on depression among STIs patients.

Data reflecting the prevalence of mental health problems, their association with depression and comprehensive effects on depression among STIs patients are limited. The purposes of our study were: (1) to gain in-depth understanding of the STIs patients’ mental health status; (2) to construct a comprehensive framework about the combined effects of mental health issues on depression by applying syndemic theory; (3) to develop a preliminary psychosocial screening framework to effectively identify the prodrome of depression and to provide theoretical reference for psychosocial intervention strategies among STIs patients.

Materials & Methods

Results

Sociodemographic characteristics and their association with depression were presented in Table 1. An overall 910 interviewers completed the survey, the majority (67.5%) of which were from outpatient clinics. The average age was 38.72, with a standard deviation of 13.03. Ratio between male and female was 1:1.08. Of all the participants interviewed, 44.1% were local and 93.6% had a health insurance to pay the bill. More than half (61.8%) of them were married, followed by 30.4% unmarried, 6.3% divorced and 1.5% widowed. 86.8% reported heterosexuality. For education and monthly income level, 25.2% reported a highest education level was lower than high school and 16.3% earned less than an average of 3,000 yuan each month.

Six sociodemographic variables (age group, gender, education level, monthly income, marital status, residence status) were significantly associated with depression. Participants younger than 25 years old were about 4 times (OR = 4.12, 95% CI [2.03–8.37]) more susceptible to depression than those older than 60. Women had a higher risk of depression than men (OR = 1.65, 95% CI [1.17–2.34]). Compared to married group, unmarried status was a risk factor of depression (OR = 1.87, 95% CI [1.30–2.68]). The groups of above 6001 yuan per month was less likely to be depressed compared with the lowest group, and the lower the education level, the greater the likelihood of depression. Non-local people rose the possibility of depression approximately 2 times (OR = 1.75, 95% CI [1.23–2.50]) higher than local residents.

Discussion

The prevalence of depression of STIs patients in our study was 17.9%. Compared with the prevalence of depression with 5.1% and 3.6% in ordinary women and men, respectively, the depression status of STIs patients deserved more attention. The concurrence of two or more mental health problems with a high prevalence of 37% demonstrated the syndemic effect to magnify the depressive symptoms of the population. The more psychosocial problems STIs patients had, the more likely they were to have depression. The association between mental health issues may play important role in sydemic effect on depression.

We have found 6 possible sociodemographic factors contributing to depression among STIs patients. The depression rate of female patients was much higher than that of male patients (21.4% versus 14.1%, P = 0.004), which was consistent with an American study (51.9% versus 31.9%, p = 0.023) (Erbelding et al., 2001). Also, women had higher prevalence of STIs and depression than men in Canada (Chen et al., 2008). Unemployment and worsen relationship with sex partner after STIs diagnosis in female patients were risk factors of probable depression (Mo et al., 2015). How age got to become negative factor may be explained by higher sexual impulsivity, less awareness of the disease, lower ability to ask for help and higher vulnerability to events in the younger age group. Emotional and financial support from families and friends may explain married status and local residence as protective factors in depression development. Education degree and its related income levels, affecting medical resource, professional consultant and cost of medication can also be blocks to psychosocial health.

In traditional belief, sexually transmitted infections were considered as social stigma and a shame not only to individual but also to the family (Lichtenstein, Hook 3rd & Sharma, 2005). The consequent stress as well as physical discomfort may provoke poor mental well-being (Duncan et al., 2001). In our study, all 6 psychosocial variables were related to depression, especially self-esteem, social support, entrapment and defeat played significant roles in increasing the risk of depression. Self-esteem and social support had been regarded as important resources to fight against stress and to maintain health (Thoits, 2010). According to the vulnerability model of depression (Orth & Robins, 2013), lower self-esteem can put individuals at a higher risk of depression when confronting significant stressors. Consistent with the vulnerability model, it had been shown in a meta-analysis of 95 longitudinal studies that low self-esteem carried significantly stronger effect on depression (β = −0.16) (Sowislo & Orth, 2013). Studies had also verified the perception of social support (available assistance, receiving actual help and integration in a social work) can prevent the risk of depression (Liu, Gou & Zuo, 2016; Maeda et al., 2013; Sonnenberg et al., 2013). Usage of Internet was encouraged by a study on social media who discovered that the more social support people thought they perceived from social media, the less likely they would be trapped in depression (Park et al., 2016). The social support intervention by social media can be carried out in STIs patients to ease the mental health burden.

The results found, in agreement with previous studies, that entrapment and defeat were important predictors of depression, which was also applicable to STIs patients. The concept of entrapment (an inability to escape from adverse situations) and defeat (failed social struggle) derived from the social rank theory of depression (Gilbert & Allan, 1998). Many of evolutionary theories noted that “failed struggle” can be considered as the essence of depression onset. The feelings of entrapment and defeat can emerge from unacceptable or relatively novel issues, social threat, stressors. To our knowledge, these are common problems encountered by STIs patients. The previous studies had shown clear and robust correlation between entrapment, defeat and depression (Gilbert & Allan, 1998; Griffiths et al., 2014; Taylor et al., 2011; Trachsel et al., 2010). Furthermore, a previous systematic review reported that self-perceived defeat and entrapment played key roles in depression, anxiety, suicidal tendency, and post-traumatic stress disorder, and emphasized that entrapment played a decisive role in depression (Siddaway et al., 2015). There were implications for targeting perceptions of entrapment and defeat within psychosocial interventions for STIs patients suffering from depression and screening the population to identify those at risk of developing depression.

The most significant finding of the study was that psychosocial syndemic revealed a magnifying effect in predicting depression status of STIs patients. The interaction between psychosocial variables led to the coexistence of psychosocial problems. The self-esteem antecedent model argued that self-esteem had an effect on social support. Specifically, higher self-esteem can get individuals to develop positive social support networks because of their belief in their social worth, while those with lower self-esteem had difficulties in establishing positive social support systems because they usually avoided social interaction due to their worry about being rejected by others (Marshall et al., 2014). On the other hand, the self-esteem consequence model pointed out that positive social support can produce higher self-esteem (Leary, 2005). The mediation effect of social support on loneliness and depression can shed light on the concurrence effects of loneliness and social support on depression (Liu, Gou & Zuo, 2016). In addition, some researcher conducted factor analysis to verify entrapment and defeat were best defined as on factor, suggesting that the perceptions cooccurred and led to development of mental disorders (Griffiths et al., 2015; Griffiths et al., 2014). Therefore, we integrated various mental health issues and formed a comprehensive framework for the preliminary evaluation of depression among STIS patients. As a conclusion, a high number of psychosocial problems indicated a greater potentiality of depression.

Conclusions

Our study reviewed the contribution of each psychosocial variable to the development of depression in sexually transmitted infections patients and extended the literature into the study. The correlation between psychosocial problems and depression was confirmed, and a syndemic effect of psychosocial problems on increasing odds of depression was identified. We emphasize the importance of early and integrated psychosocial intervention to alleviate their mental burden so that the occurrence and progression of depression can be blocked.

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