Background: Depression in HIV-infected pregnant women is a public health problem
due to its negative effects on both maternal and child health, and, on adherence to
HIV/AIDS medication regimens. Evidences suggest that nutrient deficiencies may
further enhance the depressive illness and that fish oil omega-3 fatty acids may
alleviate the depressive illness.
Objective: The study aimed at assessing the effect of fish oil omega-3 EPA-rich
supplements on BDI-II depressive symptom scores among HIV-seropositive pregnant
women.
Methods: This study was an interventional randomized controlled trial with two
parallel groups of fish oil omega-3 as intervention and soybean oil as control. It was
double-blinded to participants and those administering the interventions including the
principal investigator. Participants were HIV-positive pregnant women enrolled in
Prevention of mother-to-child transmission programs and attending antenatal clinics
at Nairobi city council‟s Riruta Health Centre, Mathare North Health Centre,
Kariobangi North Health Centre and Kayole-II Sub-district Hospital. Recruitment was
from health records of HIV-positive pregnant women. The study inclusion criteria
were CD4 cell count of not more than 500 cells/µl, second trimester of pregnancy at
14 to 27 weeks, and participation consent. In addition, all participants had at least
mild depression according to Beck Depression Inventory Second Edition (BDI-II)
scale. Standardized individual questionnaires were used to collect data on
participants‟ demographic, socio-economic, health and HIV-related characteristics.
Dietary intake data was collected using a food-frequency checklist and 24-hour
dietary recall methods. Daily nutrient consumption values were computed from food
composition databases. Recommended daily allowances for pregnant women were
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used to compute dietary adequacy. Omega-3 EPA and DHA cellular levels were
determined from cheek cell samples by gas chromatography method. Change in BDIII
depressive symptom scores was computed as post-intervention BDI-II scores (at
end of study) minus baseline BDI-II scores (at week 0).
Data analysis: Participants‟ characteristics data (age, gestational age, HIV status,
marital status, parity, education, employment, knowledge of serostatus before
pregnancy, HIV status disclosure to anyone, support group meetings attendance and
stressful life events experienced) were summarised as median and inter-quartile
ranges and proportions. Data analysis followed per-protocol analysis method with
participants who completed the 8-week trial included in the analysis of covariance
statistical model with fish oil as the main effect and participants‟ baseline
characteristics and nutrient adequacy as covariates in change in BDI-II depressive
symptom score outcome. The presence of interaction between covariates was tested.
Results: The study recruited 282 participants and randomized 109 to receive fish oil
group and 107 to receive soybean oil group. Most participants had mild to moderate
depressive symptoms with BDI-II scores of Median (IQR): 20(16-25) in experimental
group and 21(17-25) in control group. Baseline attributes were all similar in both
study groups. Completion rate was 78.9% (n=86) in experimental group and 89.7%
(n=96) in control group. Dietary nutrient intake was below the estimated average
requirements for pregnant women for all nutrients under investigation in more than
60.0% of participants in both groups except for vitamin C (baseline: Fish oil = 56.9%,
Soybean = 55.1%); week-8: Fish oil: 44.2%, soybean oil: 40.6%) and vitamin B1
(week-8: Fish oil: 46.5%, soybean oil: 42.7%) and zinc (week-8: Fish oil: 44.2%,
soybean oil: 46.9%). Poor concentration of omega-3 EPA and DHA fatty acids in
both groups was also noted, with no significant difference between the fish oil
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experimental group and soybean oil control group at baseline (EPA (z=0.32; p=0.74)
and DHA (z=-0.78;p=0.43)), and after intervention at week-8, EPA (z=0.61; p=0.54)
and DHA (z=-1.70; p=0.09)). The participants in both groups had mild to severe BDIII
depressive symptoms (Fish oil: mild=43.1%, moderate=42.2%, severe=14.7%;
soybean oil: mild=43.0%, 44.8%, 12.1%) before randomization. The intervention
effect, all baseline attributes held constant, was not statistically significant at week-4
(0.14 (95% CI: -1.51 – 1.78), p=0.87) and week-8 (0.85 (95% CI: -0.73 – 2.44),
p=0.29). The change in BDI-II scores was significantly associated with baseline BDIII
scores, -0.87 (95% CI: -1.02 - -0.72; p=0.000) parity status -2.23(95% CI: -4.38 – -
0.09, p=0.04) assuming all other covariates were held constant.
Conclusion: Fish oil omega-3 EPA-rich supplementation with a daily dosage of 3.17
grams (EPA=2.15 grams; DHA=1.02 grams) is not effective in reduction of
depressive symptoms among HIV-infected pregnant women with mild, moderate and
severe depression symptoms. The fish oil omega-3 supplements are however welll
tolerated, with no adverse side effects among the HIV-infected pregnant women.
Severity of depressive symptoms at baseline and maternal parity status can
significantly cause a reduction in change in depressive symptoms severity in an 8-
week intervention period. This study recommends inclusion of routine screening for
depression among HIV-infected pregnant women for timely management of women
with severe depressive symptoms. A more focused nutrition assessment, counseling
and support for this vulnerable population at the antenatal care is also recommended.
Future research on fish oil omega-3 and depression in HIV-infected pregnant women
should focus on either moderately depressed or severely depressed women separately