Links between HIV and mental illness overlooked

The links between HIV and mental illness are so multi-layered, and little understood, that doctors often struggle to determine which came first. Mental healthcare professionals in South Africa sometimes battle to understand the causes of a patient's psychosis or dementia, without knowing that the patient has a late-stage HIV infection, while their colleagues in the HIV/AIDS sector have little or no training on how to deal with patients with mental illnesses.

"There are no specific mental health services for people living with HIV," said Prof Melvyn Freeman, co-author of a study by South Africa's Human Sciences Research Council, which found that 44 percent of a sample of 900 HIV-positive individuals were suffering from a mental disorder.

Mental illnesses can themselves be risk factors for HIV. Some mental disorders lead to greater promiscuity; others can make sufferers more vulnerable to sexual abuse and exploitation. Even depression can increase an individual's HIV risk.

"If you don't feel there's much point in your own survival, you don't see the point in taking precautions to protect yourself," noted Freeman, who has advised the UN World Health Organisation on how better to integrate mental health into its HIV/AIDS initiatives.

There are no specific mental health services for people living with HIV

Conversely, people with HIV are more likely to develop mental illness than the general population. The effects that HIV and AIDS can have on an individual's mental health range from the depression and anxiety that may accompany an HIV-positive diagnosis, or the death of loved ones, to the dementia and psychosis that can occur when the disease becomes more advanced and affects the brain.

"One of our biggest challenges in psychiatry is this epidemic," said Dr Greg Jonsson, a psychiatrist at the vast Chris Hani Baragwanath Hospital, on the outskirts of Soweto, Johannesburg's most populous township. "We weren't really trained in HIV; [psychiatrists] were sending these patients to ARV [antiretroviral treatment] clinics, and the problem with that was they weren't trained in psychiatry."

The end result, said Jonsson, was that patients with psychiatric problems were being marginalised and often excluded from treatment, on the basis that they were not considered capable of remembering to take the pills every day. Non-compliance while on ARV treatment results in the development of drug-resistant forms of the virus that are even more difficult to treat.

"We know people who have neuro-psychiatric disorders related to HIV respond to ARVs," said Rita Thom, a psychiatrist at the University of Witwatersrand who has researched mental disorders in HIV-positive people. Ensuring that the patients get the drugs is the first major hurdle, added Thom; helping them to adhere to the drugs is the second.

One-stop shop

With funding from the Aurum Institute for Health Research, an independent medical scientific organisation, Jonsson, along with a nurse, an occupational therapist and a psychologist, decided to open a special clinic at Baragwanath's psychiatric section for HIV-positive patients who were also suffering from mental illness.

"The goal is to treat the HIV and also treat the mental illness, because at the ARV clinics they're so overwhelmed that they don't pick up on the depressions and the dementias and the anxiety," said Jonsson.

Starting in March, the clinic has become a one-stop shop for patients to pick up both their psychiatric and HIV medication, meet with Jonsson and, if they are able, participate in a support group.

The group meeting on a recent Friday at first proceeds like any other.

Linda* talks passionately about the difference ARV treatment has made to her health, while Zanele* voices her ambivalence about starting the life-long drug regimen. The facilitator explains the difference between HIV and AIDS, and how ARV drugs can help, but are not a cure.

"So HIV can't be cured?" asks Sipho*, a young man in a baseball cap who has been quiet up until this point.

The facilitator patiently reiterates that the virus can be managed with ARVs, but that there is no cure as yet.

"What are ARVs?" asks Sipho, who is then unable to say for sure whether or not he is taking them.

Clearly, this is no ordinary support group. "Many of you are here because you don't only have HIV, you have another illness as well," says the facilitator, and the discussion takes a new turn.

Sipho tells the group he has schizophrenia. "I had a Gogo's [Zulu word for grandmother] voice crying in my throat," he says, demonstrating with a strangled growl. "My mother said I must see a doctor. Now I'm okay."

Zanele confides that she is bi-polar: sometimes she is very angry and sad, at other times very happy.

Linda is recovering her memory after being in a coma for two weeks. "I was blank until last week - it was very scary," she later told IRIN/PlusNews.

She believes the coma was brought on by stress caused by members of her community. "They saw me losing weight and they were laughing at me; they told my boyfriend I was HIV and he left me. I was very stressed out," she said.

Although stress may have played a role, according to her doctor, it was an HIV-related disease - tubercular meningitis - that caused Linda to slip into a coma and subsequently lose her memory. Her fairly rapid recovery in recent weeks is probably the result of her taking TB drugs and then beginning ARV treatment earlier this month.

"My sister used to have to remind me [to take the pills], but now she doesn't have to," Linda said proudly.

No guidelines

There are no special guidelines on how to adapt HIV/AIDS treatment to the special needs of psychiatric patients, but according to Jonsson and Liselle De Wee, the clinical psychologist who facilitates the support group, education plays a vital role in helping patients who find it difficult to adhere to their medication schedules.

Clinic staff frequently repeat and reinforce information about how patients should take their medication and encourage patients to choose a treatment "buddy" - a family member or friend who will remind them to take their daily drugs.

"People recovering from psychosis might not be able to integrate information as well as other people," said De Wee after the support group meeting. "You always have to check that the penny has really dropped."

While ARVs will treat the HIV infection and usually help with HIV-related dementia, other drugs may be needed to manage unrelated mental illnesses like schizophrenia. According to Jonsson, interactions between the two sets of drugs are another source of "huge problems" that still require more research.

Mental health services in short supply

Other than the new clinic at Baragwanath, which only has about 45 patients, South Africa's public health sector has no specialised mental health services for people living with HIV. Psychiatrists and psychologists prepared to work for the state are in short supply, and those willing to work in the field of HIV are even rarer.

"The other psychologists in my department, not all of them want to be involved with this. HIV is very draining and they have other interests," said De Wee, who volunteers her time to work at the clinic. "I've got a passion for this, and if it wasn't for that I definitely wouldn't be here."

The need to incorporate mental health services into HIV/AIDS treatment is clear. "The models are: you either bring specialist mental health professionals into the [HIV/AIDS] service, or you train the HIV professionals to deal with it; what probably needs to happen is a bit of both," said Rita Thom, the psychiatrist from Witwatersrand University.

"Mental health services are so underdeveloped in South Africa that if we can piggy back on HIV services, we might improve services for everyone."

*Not their real names

ks/he