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Mental health and HIV/AIDS:


Mental health and HIV/AIDS: A psychosocial and cultural perspectives Dr Kanda MA 8 March 2013 Lebowakgomo Hospital One virus but many stories 1 Blondie is a 35 years ... – PowerPoint PPT presentation

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Title: Mental health and HIV/AIDS:

Mental health and HIV/AIDS
  • A psychosocial and cultural perspectives

Dr Kanda MA 8 March 2013 Lebowakgomo Hospital
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

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.

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.

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

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.

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

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.

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 parents 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
    Jeannettes 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.

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.

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
  • 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

Mental health disorders in people with HIV
  • Psychological reactions to HIV the diagnosis of
    HIV/AIDS is a stressful event and very often
  • 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

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

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

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
  • 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

Mental health disorders in people with HIV
  • Common mental disorders
  • Anxiety include PTSD, obsessive-compulsive
    disorder, panic attacks and generalised anxiety
  • 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

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

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
  • Severe form of HAND is HIV-associated dementia
    impact on the capacity to work and activities of
    daily living, difficulty with writing, speaking,
  • Differential diagnosis with depressive

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

  • 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.

  • 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
  • Do not forget cultural issues
  • Thank you