Mental illnesses associated with HIV infection go undiagnosed in South Africa

From IPS:

CAPE TOWN, South Africa - Although mental disorders, such as depression and dementia, are a commonly associated with HIV, they remain largely undiagnosed in South Africa. Lack of human and financial resources for mental health are the main reason for this, researchers say.

A team of scientists at the University of Cape Town’s psychiatry and mental health department has now embarked on designing guidelines to help South African nurses and adherence counsellors to routinely screen HIV-positive patients for mental disorders and to better manage, treat and refer patients.

Yet, health workers won’t be able to use these guidelines efficiently, if the South African Department of Health (DoH) does not provide a sufficient budget for this sector.

According to the South African Depression and Anxiety Group (SADAG), a national mental health support and advocacy organisation, the DoH spends less than one percent of the national health budget on mental health services. Only seven percent of the country’s health facilities have specialised teams for mental health, while only nine percent of hospital beds are reserved for psychiatric patients.

"HIV attacks the brain quickly, and we therefore see an increase of all mental disorders [in HIV-positive patients]," explained UCT HIV neuro-psychiatrist John Joska, who is leading the research on the mental health screening tool.

"Unfortunately, mental illness is not seen as an integral part of care for people on ARV [antiretroviral] treatment. As a result, patients are under-diagnosed and under-treated."

The human immunodeficiency virus contributes directly to depression, dementia and other mental illnesses. Psycho-social stress due to loss of relationships, dealing with being HIV-positive and death put further strain on mental well-being, explains Joska. In addition, ARVs can also cause negative side effects to a patient’s mental health.

"Depression is at least twice as common in HIV-positive than in HIV-negative people," he said, pointing out that almost one in ten HIV-positive patients are suicidal.

A 2005 study by adjunct professor Rita Thom of the psychiatry division of the University of the Witwatersrand in Johannesburg, which surveyed 302 patients attending four ARV clinics in Gauteng and Limpopo, found that one out of five HIV-positive persons suffered from depression and anxiety disorders.

As a result, they adhere poorly to treatment, stop going for check-ups and have higher risk of morbidity and mortality.

"Mental illness, such as depression, also adds to immune suppression," said Joska. "They get sicker quicker, then use more health services, need more hospitalisation and have LOWER quality of life."

Although mental health screening is theoretically part of the DoH'S HIV treatment guidelines, public health care providers fail to routinely screen for mental disorders.

"Primary health care facilities are over-burdened and short-staffed. Health workers are often not skilled enough to identify mental illness or don’t have enough time to spend with each patient to identify it," Thom told IPS, adding that only five percent of HIV patients with psychiatric disorders are identified in South Africa.

Sue Roberts, a nurse and project manager at Helen Joseph Hospital’s Thembalethu AIDS Clinic in Johannesburg, agrees: "Scarcity of human resources is a huge problem. Although some health workers have the skills, most don’t have the time it takes to talk in depth with the patient to diagnose mental illness."

Roberts further notes that outside of urban centres, supply of medication to treat mental disorders is not always available and referral systems to hospitals with specialised mental care are not in place.

"This shows why it’s very difficult to get mentally ill people help, even if they are diagnosed," said SADAG CEO Elizabeth Matare. "This is of grave concern. It needs immediate action, political will and a public acknowledgment of the circular relationship between HIV and mental health. People with HIV are 36 times more likely to commit suicide."

SADAG believes ten to 15 percent of the country’s health budget needs to be dedicated to mental health. "Politicians need to realise that, in the long-term, it costs more to ignore the problem than to provide treatment," Matare explained.

Francois Venter, clinical director of the Reproductive Health and HIV Research Unit (RHRU) of the University of the Witwatersrand, agrees that without proper budgeting, mental health services cannot be improved. "If mental health, and its inter-relationship with HIV, are not prioritised in the system and we don’t have the resources needed, than treatment becomes rhetoric."

"It’s very frustrating. Public mental health services are few and far between in South Africa because we don’t have the commitment and resources from the national health department," added Thom.

Mental health care is generally relegated to specialised units in tertiary hospitals, while it is hardly ever offered on primary health care level - in the clinics that are the first point of entry to health care for most South Africans.

Already in August 2007, a national task team of psychiatrists submitted a proposal to the national Department of Health (DoH), then headed by Manto Tshabalala-Msimang, which suggested ways to improve the integration of mental health and HIV treatment and care. The department acknowledged receipt of the document but, two years later, has not responded to the group, says Joska.

Ideally, primary health facilities should become one-stop shops for voluntary counselling and testing (VCT), HIV treatment and care, treatment of opportunistic infections, such as tuberculosis, and mental health care, in combination with a functional referral system to hospitals for specialised and acute care.

The screening tool is meant to be a first step towards changing this. The first phase of the research will be completed by July, and Joska plans to present its results to the Western Cape health department as well as to non-governmental organisations training lay counsellors.