World AIDS Day: Experts highlight the importance of mental health care

Making a difference: Assoc Prof Crick Lund (second from right, front) and Thandi van Heyningen (far right, front) with other members of UCT's PRIME team.

People living with mental illness may act in ways that increase their risk of HIV infection. Equally, persons living with HIV/AIDS, and more so, pregnant mothers, are highly vulnerable to developing depression and other mental illnesses. A number of projects led by UCT are working on integrating mental health services into HIV, primary and maternal health care.

As countries mark World AIDS Day on 1 December and the international community consolidates its fight against the epidemic, recent research points to a hidden public health problem that plays a key role in perpetuating HIV: that of mental illness.

So what has mental illness got to do with HIV/AIDS?

The answer lies in the fact that people living with mental illness may act in ways that increases their risk of HIV infection. For example, people with a substance abuse conditions would be more likely to indulge in risky sexual behaviour, thereby increasing their risk of HIV infection.

Equally, those who already have HIV/AIDS can suffer from mental illness as a result of their HIV status.

This is due to various factors, including the effect of HIV on the brain, the psychological effects of being diagnosed with HIV, and the associated stigma and discrimination. This effect is particularly strong for pregnant mothers.

Research indicates that many women only find out about their HIV infection (the incidence of which is high among women of child-bearing age) after being screened for antenatal care. As a result of both pregnancy and HIV independently rendering women vulnerable to mental health problems, this makes them 'doubly vulnerable' to developing depression and other mental illnesses, according to clinical psychologist and research co-ordinator at UCT's Perinatal Mental Health Project, Thandi van Heyningen.

"The link between being diagnosed with HIV and depression is quite logical," says Associate Professor Crick Lund of the UCT Centre for Public Mental Health. "If you have just found out that you have a life threatening illness, particularly if it is an illness that is likely to affect your unborn child, you are likely to feel down and despondent. If you combine that with living in circumstances of poverty and having few social supports, this can rapidly lead to depression, which may have a series of negative consequences for the mother and her infant."

A brief screening tool and supportive counselling intervention, integrated into routine care, can, says Lund, carry multiple benefits for the mother and her infant, including improved mother-infant bonding and better ARV adherence.

"Such interventions need not be costly, but the return on investment for population health is potentially enormous."

In South Africa, up to now, many of the resources of the Department of Health have been allocated to the HIV/AIDS epidemic as a key priority, according to Professor Melvyn Freeman, the chief director of non-communicable diseases in the national Department of Health.

Referring to the competition for resources with HIV/AIDS, one mental health activist and person living with mental illness added that it was ironic that such competition for public health resources existed, as "many people with HIV/AIDS develop mental health problems, and at some point, will access mental health services".

There are a number of projects within UCT that are addressing mental health within the context of the HIV/AIDS epidemic. These focus on the integration of mental health into HIV care, as well as, looking more broadly at the integration of mental health care into maternal and primary health care systems.

One project known as the Groote Schuur Hospital-HIV Mental Health Group, which aims to increase the provision of mental health services to people living with HIV/AIDS, has recently published research which shows that numerous barriers to detection and treatment of common mental disorders (CMDs) exist.

Associate Professor John Joska and colleagues report that patients and providers tend to view depression, anxiety and substance abuse as problems of stress and not as disorders.

These attitudes make it less likely that patients suffering from these disorders will receive effective biological treatments, such as anti-depressants. Knowledge of how to diagnose and treat these conditions is often limited among primary health care staff, and they tend to rely on specialist teams to provide services.

One approach to equipping staff in primary health care settings is to develop locally validated brief screening tools for common mental disorders in persons living with HIV/AIDS. In a recently published study exploring the ability of lay counsellors to administer the Substance Abuse and Mental Illness Symptom Screener (SAMISS), it was found that 20% of patients on stable antiretroviral therapy (ART) reported symptoms of either depression or anxiety.

Lay counsellors tended not to miss cases, when compared to mental health nurses, but in their efforts to clarify symptoms, they sometimes over-diagnosed them. The need to offer training to staff in primary health care to diagnose and treat CMDs is great.

Another project, the PRogramme for Improving Mental health care (PRIME), headed by Lund, wants to develop evidence for the scaling-up of treatment programmes for priority mental disorders, such as alcohol abuse, depression (including maternal depression), psychosis and epilepsy, in low-resource settings. The study countries in which PRIME is working to develop research evidence include three in Africa (Ethiopia, India & South Africa) and two in Asia (India & Nepal).

PRIME is also collaborating with policy-makers in the ministries of health in study countries. In countries where the HIV prevalence is high, PRIME will be tailoring their interventions to suit the local context.

Freeman, of the South African Department of Health, added that PRIME, as an international group with lots of skills and experience, offers the department an ideal opportunity to move in the direction of integrating mental health care into general health services. As part of this project, the University of KwaZulu-Natal is collaborating with the Department of Health to integrate mental health services into the new primary health care revitalisation programme that is being rolled out in the North West Province.

The aim of these projects, respectively, are to decrease the impact of mental illness on those living with HIV/AIDS (including pregnant mothers); and through the scaling-up of mental health care, minimise the risk of people with mental illnesses contracting HIV/AIDS. Practically, this might include routine screening for depression among people who test HIV positive, or routine antenatal screening for mental health problems among pregnant women.