Mental health and HIV/AIDS:

1. Mental health and HIV/AIDS: A psychosocial and cultural perspectives Dr Kanda MA 8 March 2013 Lebowakgomo Hospital

2. One virus but many stories 1 Blondie is a 35 years old woman previously treated for Bipolar Mood Disorder while she was on HAART. Blondie had defaulted treatment both for HIV and BMD for more than a year. While waiting for her consultation at the psychiatric clinic she started praying loudly and moving along the waiting corridor on her knees. When brought in the consultation room she was observed to be clean and appropriately dressed and she looked physically fine. On interview she admitted to have stopped her psychiatric medication and first she denied being HIV positive. She later admitted to have been tested HIV positive and that she was on HAART. She then claimed to be HIV negative because her CD4 count was high and was told that she does not need the medication currently.

3. One virus but many stories 1 She stated that she stopped the medication as she was looking after her elder sister who is treated for renal failure and is severely ill. She added that the she was very worried about the sister and her own situation of being unemployed and sick single parent of two children. She stated that the more she worried the more she saw demons coming to her day and night while awake. The more she prayed the more demons came to her. She could feel the uncomfortable sensation in her abdomen when the demons come. She believed her situation was caused by the demons who made her and her family suffer.

4. One virus but many stories 2 Gift is a 29 years old female client brought by her father with the help of the police for abnormal behaviour. She runs around at home and says she sees snakes and other strange animals and she also neglect her three months old baby. Gift has 4 children. The last born baby was conceived when her third born child was 3 months old. Gift looked wasted and well kempt. As she related her story she became calmer to the astonishment of her father. She admitted seeing snakes coming to her.

5. One virus but many stories 2 She admitted that she is HIV positive and has dropped out of tertiary school because of her pregnancies. She stated that she is concerned about her situation of being unemployed and single parent of 4 children and being looked after her parents who are pensioners. She disclosed that she thought of herself as useless, and people did not value her. She said she was not sharing her problems to other people as she thought she will be judged as a mad person. She disclosed that she was scared of being mad. Because of the fear she did not tell people about her seeing the scaring animals. She felt like running.

6. One virus but many stories 3 Thato is an obese woman in her mid-thirty referred to the psychiatric clinic from casualty for abnormal strange body movement without loss of consciousness. She came in accompanied by her mother. The client has been treated for the same strange behaviour and hypertension some years ago. She had disclosed previously that she has had about six abortions and denied to have had an HIV test. She disclosed that her first pregnancy was from a sexual abused by her own father when she visited him in Gauteng in the mine when she was about sixteen. As she recounted this abuse she became tearful and agitated. She added that she was also having Moea. She was already on treatment for hypertension.

7. One virus but many stories 3 During her admission for observation of the movement and hypertension, her HIV test came positive. She initially refused to admit the test result. After discharge, she came back for review and while waiting she started talking in a strange voice stating that she is a demon and she was moving as being in trance. The mother and client stated that the client wanted to go for traditional healer initiation (Moea) but the parents were opposed as they are Christian with the father having an elder position in the church.

8. One virus but many stories 4 Jeannette is a woman in her thirty who came in with her old school friend. She was asked to come to psychiatric clinic from the HIV clinic. The friend stated that Jeannette was behaving strangely, refusing to eat, neglecting her personal hygiene and her medication and having poor sleep. Jeannette admitted refusing eating and taking medication. She believed that her old school friend was bewitching her by poisoning her food as she wanted to kill her and her children.

9. One virus but many stories 4 Jeannnette had lost her job because of her ill health. She is a single parent of three children living alone in her parent’s house. One day she collapsed at home and she asked her children to call her old school friend to come and assist her and her children. This friend living not far from Jeannette’s place came in and has been taking care of Jeannette and her children. Jeannette admits that the friend is very supportive and caring. However she is not improving like other people on HAART. She is scared of dying and leaving her three children without parent as all her family members are away. While thinking a lot she suspects that the friend is bewitching her. Physically she is very wasted and looks sick.

10. One virus but many stories 5 Merriam is a woman in her fifties. She is treated for a psychotic episode due to general medical condition. She tested HIV positive when she was at the clinic for headache. The test was part of HCT campaign. After the test she presented psychotic features and was treated with antipsychotic medication. She is living alone as the husband left her many years ago and the children are away doing piece jobs. She said she has no boyfriend and claims to have a Tokolotsi which bite her on the head and “gave” her HIV.

11. Mental health disorders in people with HIV • Range from mild distress to severe and major psychiatric conditions • Need for differential diagnosis as many symptoms of mental disorders overlap with neurological conditions • Based on DSM-IV and ICD 10, said to be reductionist, without lab tests for psychiatric conditions with experts from industrialised and Western world • What is disruptive or abnormal behaviour in one culture might not be in another. Need for research in different culture and society

12. Mental health disorders in people with HIV • Psychological reactions to HIV: the diagnosis of HIV/AIDS is a stressful event and very often traumatic • These psychological reactions are different from mental conditions based on duration, the extend of severity and daily functional impairment. • The psychological reactions can involve into major psychiatric conditions

13. Mental health disorders in people with HIV • The psychological reactions are categorised as: • Normal: fear, fury, denial, depression, withdrawal • Neurotic: exaggerated reactions such as panic, extreme avoidance behaviours, and impairment of ability to love and work; • Psychotic: • Psychosomatic: with more somatic manifestations

14. Mental health disorders in people with HIV • HIV disease raises the following major psychological concerns: • Existential and spiritual issues • A perception of HIV as a threat or persecutor • Feelings of vulnerability and loss of control • Death related concerns • Pain and suffering concerns

15. Mental health disorders in people with HIV Common mental disorders: • Depression: up to 50% of clients suffer from depressive disorders during the course of their illness. • MDD: persistent low mood, low self-esteem, decreased energy, loss of interest or pleasure in normal enjoyable activities, disturbance of sleep and appetite with weight gain or loss and suicidal ideas • Also consider post-partum/ natal depression which occurs within the first 6 months • Drug induced depression: eg. Efavirenz • End of life depression and bereavement • Suicide: the risk is up to 36 times greater than in HIV negative population

16. Mental health disorders in people with HIV Common mental disorders: • Anxiety: include PTSD, obsessive-compulsive disorder, panic attacks and generalised anxiety disorders • Adjustment disorder: less likely to have clients with negative self-image or suicidal ideas • Alcohol and cannabis-related disorders • Worried well clients: high risk group obsessed about being HIV positive despite many HIV negative tests

17. Mental health disorders in people with HIV Major psychiatric conditions: • Bipolar Disorder • AIDS mania: generally in end stage of HIV infection and may be due to opportunistic infections or HIV • Schizophrenia Other disorders: • Sexual dysfunction • Sleep disorders • Personality disorders:

18. Mental health disorders in people with HIV HIV-associated neuro-cognitive disorders (HAND): • Asymptomatic neurocognitive impairment (ANI): only detected with neuropsychological testing • HIV-associated mild neurocognitive disorder (MND) which is clinical: slow movement and thought process, poor concentration and short-term memory, difficulty to carry out complex activities • Severe form of HAND is HIV-associated dementia: impact on the capacity to work and activities of daily living, difficulty with writing, speaking, walking, Differential diagnosis with depressive disorder

19. Mental health disorders in people with HIV Medical emergency: • Delirium: disturbance of consciousness and a change in cognition that develops very often over a short period of time. • Delirium is generally under recognised and under diagnosed and needs to be identified and its underlying treated urgently • Clinical manifestations: abnormal arousal, impaired orientation, language abnormalities, impaired memory, perceptual disturbances (hallucinations), abnormal mood Differential diagnosis with psychotic episode

20. Management • Delirium: treat underlying cause, for sedation use lorazepam 2-4 mg PO separately or in association with haloperidol 0,5 mg PO. To avoid EPSE advise to use Risperdal 0,5 mg PO • Psychotic episode due to HIV/AIDS: haloperidol 0,5-1mg PO daily or Risperdal 0,5-1mg PO daily • Mood disorder due to HIV/AIDS: avoid tricyclic because of the side-effects and risk of suicide, Use SSRI at lower dose. Sodium valproate may accelerate viral replication and carbamazepine may be used. Some herbal medication may interact with ARVs.

21. Management Psychosocial interventions: improve quality of life and functioning. They could be: • Emotion focused • Problem solving focused • Support focused • Meaning focused “Frequently our science and medical skill are insufficient and our patients need counsellors who are sensitive to psychological, social, ethical and spiritual issues in their lives” Spencer, D.C. 2005. The Clinical Practice of HIV Medicine. Do not forget cultural issues Thank you